ORIGINAL RESEARCH CONTRIBUTION

Work Pressure and Patient Flow Management

in the Emergency Department: Findings From
an Ethnographic Study
Peter Nugus, MA(Hons), MEd, PhD, Anna Holdgate, MBBS, Margaret Fry, MEd, PhD, Roberto Forero,
MA, MPH, PhD, Sally McCarthy, MBBS, MBA, and Jeffrey Braithwaite, MBA, MIR, PhD, FAIM,
FCHSE

Abstract
Objectives: In this hypothesis-generating study, we observe, identify, and analyze how emergency clini-
cians seek to manage work pressure to maximize patient flow in an environment characterized by
delayed patient admissions (access block) and emergency department (ED) crowding.
Methods: An ethnographic approach was used, which involved direct observation of on-the-ground
behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent
observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses,
emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and
thematically analyzed more than 800 pages of field notes to identify indicators of and responses to
pressure in the day-to-day ED work environment.
Results: In response to the inability to control inflow, and the reactions of inpatient departments to
whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions;
negotiated and determined patients’ admission–discharge status early in their trajectories; pursued
predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised
flexibility to reduce work pressure by managing scarce time and space in the ED.
Conclusions: To redress the linearity of most literature on patient flow, this study adopts a systems
perspective and ethnographic methods to bring to light the dynamic role that individuals play, interact-
ing with their work contexts, to maintain patient flow. The study provides an empirical foundation,
uniquely discernible through qualitative research, about aspects of ED work that previously have been
the subject only of discussion or commentary articles. This study provides empirical documentation of
the moment-to-moment responses of emergency clinicians to work pressure brought about by factors
outside much of their control, establishing the relationship between patient flow and work pressure. We
conceptualize the ED as a dynamic system, combining socioprofessional influences to reduce and control
work pressure in the ED. Interventions in education, practice, policy, and organizational performance
evaluations will be supported by this systematic documentation of the complexity of emergency clinical
work. Future research involves testing the five findings using systems dynamic modeling techniques.
ACADEMIC EMERGENCY MEDICINE 2011; 18:1045–1052 ª 2011 by the Society for Academic
Emergency Medicine

T
he inevitable and continual arrival of patients to or maintain patient flow. High work pressure is
the emergency department (ED) challenges the workload, demands, or strain, perceived by a worker or
way clinicians manage work pressure to enhance workers to be beyond what workers usually manage

From the Centre for Clinical Governance Research in Health (PN, JB), Simpson Centre for Health Services Research (RF), Austra-
lian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney NSW; the Emergency Medicine
Research Unit, Liverpool Hospital (AH), Liverpool NSW; the Faculty of Nursing, Midwifery and Health, University of Technology
(MF), Sydney, NSW; and the Emergency Department, Prince of Wales Hospital, Barker Street (SM), Randwick NSW, Australia.
Received March 14, 2011; revision received May 28, 2011; accepted June 7, 2011.
Dr. Nugus was funded as part of a larger patient safety grant, acquired by the Centre for Clinical Governance Research
(Dr. Braithwaite is Director) to undertake a PhD. The Clinical Excellence Commission of New South Wales who funded the
project had no input on the findings.
Supervising Editor: Mark Hauswald, MD.
Address for correspondence: Peter Nugus, MA(Hons), MEd, PhD; e-mail: p.nugus@unsw.edu.au. Reprints will not be available.
A related commentary appears on page 1090

ª 2011 by the Society for Academic Emergency Medicine ISSN 1069-6563

doi: 10.1111/j.1553-2712.2011.01171.x PII ISSN 1069-6563583 1045
1046
comfortably in their day-to-day work.1,2 Patient flow is
the passage of multiple patients through a complex, intri-
cate process with the aim of delivering high-quality care
to individuals, and efficiency and effectiveness across the
department and hospital. Studies and models of the flow
of ED patients are usually unidimensional and emphasize
linear, staged progress, architectural aspects of EDs
based on their physical design, measurement of outputs,
or numerical performance indicators of the quality and
efficiency of care delivered.3–5 Such accounts are impor-
tant; however, they can also be complemented by a sec-
ond perspective exploring the way staff seek to manage
the increased work pressure associated with the dynamic
complexity of patient flow.
The importance of investigating work pressure in ED
flow is highlighted by research showing the interaction
of EDs with processes outside of them.6–9 For example,
‘‘access block’’ (the inability to transfer patients from the
ED to hospital wards) and ED overcrowding (where
patients come faster than they can be treated and trans-
ferred) stem mainly from processes in other departments
of the hospital, resulting chiefly from an undersupply of
inpatient beds.10 Access block and ED overcrowding
have been associated with indicators of work pressure:
high staff turnover and staff dissatisfaction.11–13 Access
block and ED overcrowding are also significant threats
to patient safety. Overcrowding in the ED can lead to
decreased compliance with clinical guidelines, inappro-
priate decision-making,10 an increase in the number of
adverse events,14,15 and increased mortality rates.16,17
Some studies have demonstrated increased aggres-
sion from ED overcrowding, as an indicator of work
pressure.18
This study contributes to research that has estab-
lished the association between patient flow and over-
crowding.10,19 Patient flow is complicated by the need
to reconcile the tension between the urgency and com-
plexity of patient conditions.20 Available literature and
models of patient flow tend to conceive patient flow as
a linear process. The innovation of this study is to rec-
ognize the way individuals serve as dynamic players in
the ED and health systems and how they interact in
context to maintain patient pathways. Ethnographic
methods, designed to account for action and interaction
in real contexts, are uniquely engaged to explain how
emergency clinicians manage workflow and crowding.
Ethnography is a qualitative research strategy involving
immersed and prolonged observation of what people
do and how they do it.21 The aim of these observations
was to understand patterns of beliefs, activities, and
practices in sufficient depth to appreciate the complex-
ity of human interaction and relations in these case
study settings.22,23
Because ED overcrowding stems from access block
in other parts of the hospital, the processes in those
departments, therefore, put capacity constraints on
clinicians’ ‘‘agency.’’ ‘‘Agency’’ is a sociological term to
denote how capable individuals are to make their own
free choices and act independently in a complex envi-
ronment that is nevertheless to some extent constrained
by the ‘‘social structure’’—that is, whereby choices and
action are inhibited by broader resource, cultural, or
other social influences.24 Agency is exercised within a
Nugus et al. • WORK PRESSURE AND PATIENT FLOW MANAGEMENT
system of constraints. In the present context, agency is
the ability of emergency clinicians to increase patient
flow; that is, the rate at which patients are assessed and
treated, and transferred from, the ED. Thus, there is
more to patient flow than simplistically conceiving it as
the inevitable arrival of patients and the naturally
unfolding pathology of patient conditions, their treat-
ment, and discharge.
To assist in understanding broader system factors to
which emergency clinicians respond, it helps to con-
ceive of the ED as a complex adaptive system. The ED
comprises multiple webs of clinical agents that are
interdependent, mutually influencing each other and
the system itself.25,26 In a complex adaptive system,
the system and the agents are said to interact with
and influence each other over time. Individuals and
departments are able to shape each others’ behaviors
and activities because there are porous (permeable)
boundaries between, for instance, parts of a system
(such as sections within the ED), and the system’s
environment (such as other hospital departments or
the broader community).27 This system is changing
and unpredictable, so we cannot fully anticipate how
particular individuals, sections within the ED depart-
ments, or organizations or groups might respond to
particular events, such as conditions of high work
pressure.28
A systems perspective explains the multiple layers of
ED flow and overcrowding because it accounts for the
influence that broader system influences (such as lim-
ited bed capacity in the hospital and politically driven
measures of efficiency) can have on the ED and the way
individuals can respond to those influences.26 The ED is
part of a complex system that represents structural con-
straints that emergency clinicians have to manage.
These constraints are continuing arrivals fueled by
beliefs, expectations, and needs of the community;
political and managerial expectations of efficiency of
patient throughput; capacity constraints beyond the ED
(such as available beds in the hospital and services in
the community); and limited resources in the ED (such
as staff, space, time, and beds). Systems theory
accounts for the multiple layers of ED flow and over-
crowding because it describes the mutual influence
between the whole system and its various parts.26 This
study explains the management of patient flow in con-
tinual arrival of patients, prolonged stay in the ED, and
managing potentially delayed departure of ED patients.
In EDs, patients are classified along one dimension,
on the basis of the acuity of their conditions. Acuity is
often measured by triage categories.29 Triage category
1 and 2 patients are of high acuity and categories 3, 4,
and 5 are at lower levels of acuity. However, the
resource consumption (a further dimension: how much
time they take to treat, the care they need, and how
long they stay) of patients in relatively lower triage acu-
ity categories is unknown and hard to predict, poten-
tially increasing work pressure, especially if patients
have particularly complex conditions.
The ED system, featuring continual patient presenta-
tions and the need for staff to respond to those pre-
sentations, is relatively stable, tending to restore itself
to order when the work pressure is reduced by
ACADEMIC EMERGENCY MEDICINE • October 2011, Vol. 18, No. 10
transferring patients to other hospital departments or
other locations in the broader health system.30,31 This
study complements psychological studies of work pres-
sure (or ‘‘stress’’),32–34 which tend to focus on the rela-
tionship between the mental schema and behavior of
individuals, with an original, anthropological perspec-
tive that focuses on the social context of work pressure
created by broader systems in the times and places they
are happening.21 This hypothesis-generating study
aimed to deliver a better understanding of how work
pressure is managed by ED staff to improve patient
flow, and patient safety, during this critical phase of
assessment and treatment.
METHODS
Study Design
This study aimed to tackle the question: how do emer-
gency clinicians manage work pressure to maintain
patient flow, given the ED’s multiple systems variables
and dynamic complexity? To account for such manage-
ment in real time, we designed an ethnographic study,
using formal and informal observational techniques.
The study sought to appreciate the complex mix of
organizational factors affecting ED processes.
Study Setting and Population
The study was conducted in the EDs of two public,
tertiary-referral hospitals in Sydney, in the State
of New South Wales, Australia. The EDs are major
trauma units, each receiving approximately 50,000
presentations per year.
The first author (PN) observed more than 4,500 inter-
actions (or encounters) across approximately 260 emer-
gency clinicians and clinicians from other hospital
departments. More than 1,600 hours of observation
were spent in data collection. As part of the data col-
lection process, PN also accompanied 12 purpose-
enrolled clinicians (representing various roles rather
than being randomly sampled), including junior,
midranked, and senior emergency medicine and nurs-
ing staff, over two full shifts averaging 9 hours each, in
the two EDs, documenting as much of what they said
and did as possible (24 shifts over approximately
200 hours). These observations also produced data
from participants’ interactions with various other ED
staff members and staff members from other depart-
ments visiting the ED.
Study Protocol
Data collection comprised a full 12 months of ethno-
graphic observations and was clarified by informal field
interviews after shifts. Ethnography is a valuable meth-
odology for highlighting the interaction of individuals
with systems as they manage work in real times and
places. We aimed to reduce sampling bias and increase
validity across the two EDs by the observer being
ensconced in each ED for 6 months full time. Further-
more, sampling was purposive, rather than random,
covering a variety of times (day, night, weekday, and
weekend), shifts, and the perspectives of different roles
(senior and junior nurses and doctors), artifacts (such
as observing near or following the bed allocation
• www.aemj.org 1047
board, the white board, and the pathology chute), and
places (such as observing for prolonged periods in the
nurses’ station and particular sections of the ED) in
each ED.35 Human research ethics committee approvals
to conduct the research were granted by the authors’
academic institution and the hospitals in which the
research was conducted.
Data Processing and Analysis
The observations were recorded in handwritten field
notes. Analysis, conceptualization, and interpretation of
the findings were supported by the coauthors. Analysis
of the field notes involved the systematic search for
instances directly and indirectly involving the manage-
ment of patient movement through the ED, to address
the study’s aim and research question.36,37 These
instances were then organized as analytical themes.
Field notes were reanalyzed until ‘‘saturation’’ was
reached, meaning that no new themes were emerging
that varied from the derived set of analytical themes.38
Specifically, the transcripts were analyzed by hand and
through ‘‘line-by-line’’ coding.39 Data (as events or talk)
relevant to the management of patient flow were orga-
nized into themes during the analytical process rather
than as preconceived hypotheses. The validity of these
themes was tested during the analytical process by
managing variations to the emerging themes. Compari-
son of data against the themes meant that some data
were deemed irrelevant to the topic, and relevant data
either were incorporated into the themes, or themes
were adjusted to account for those data.40 This process
helped to ensure that the coding of data was systematic
rather than arbitrary. These findings emerged in a
grounded fashion; that is, we commenced with no
hypothesis, but with a purposive sampling strategy and
ethnographic methods to discern themes on this under-
explored topic. The themes emerged over time through
the research process and were iteratively tested by
revisiting clinicians, particular shift times, and scenes of
particular activity to confirm patterns. Therefore, the
themes were imposed on the data retrospectively for
the purpose of writing this article. The five analytical
themes yielded by the analysis (dynamic flow, control-
ling flow, managing section boundaries within the ED,
managing time, and external dynamics) are presented
in the findings below.
Each data excerpt in the findings section is followed
by a code that denotes which type of role was accom-
panied in observation to deliver that particular excerpt
of data. The excerpts are representative of the themes.
Codes also denote whether the data were derived from
Hospital A or Hospital B, which of the first or second
shifts contributed the data and the page number of
the field notes in which those particular data were
recorded.
RESULTS
Strategy 1—Dynamic Flow: Prioritizing Patient
Momentum
A principal finding was that, from a systems perspective,
the decision to admit or discharge patients was a key
decision of equal importance to the diagnosis and the
1048
treatment plan. This decision is a major factor in how
emergency clinicians manage their work. For this and
subsequent findings, apart from having fewer senior
doctors on duty at night and on weekends, and patterns
of variation in patient presentations, there were broadly
similar patterns discerned at different times and places
through the EDs in relation to the dynamics of managing
system constraints on patient flow. In sociological terms,
a central component of work in the ED was the need to
actively construct a flow, rather than flow just happen-
ing through the natural course of symptom manifesta-
tion and subsequent assessment, diagnosis, and
treatment. Individual patients, presenting either via res-
cue vehicle or under their own power, received five
identifiable dimensions of care: assessment; allocation to
particular sections within the ED; diagnosis, including
treatment options; internal negotiation about treatment,
admission, and discharge options; and external negotia-
tion regarding potential inpatient admission or follow-
up care or transfer to another care setting. These
dimensions sometimes but not always occur as stages,
which vary from patient to patient and usually overlap.
How these dimensions are distinguished is a matter of
preference, but they describe the template pattern of ED
patient flow.
Triage category is a classification of treatment
urgency. The assigned classification did not necessarily
overlap with patient acuity. That is, there was some-
times a difference between how urgently treatment was
required and how ill the patient was perceived to be.
These are crucial judgments in emergency clinical prob-
lem-solving. Broad categorization of the clinical condi-
tions of patients was intimately related to patient flow.
Before the end of a shift, a registrar explained to the
observing researcher:
‘‘I’ll just tie up loose ends with two patients … If
there are a lot waiting, [those waiting the longest]
get left. [The biggest challenge is treating category
three and four patients, ie. those less urgently ill].
The idea is to treat them and get them home. The
sicker ones will sort out themselves.’’ (Mid-ranked
doctor, Hospital A, Shift 1, p. 27).
The ‘‘engine room,’’ or hub, of emergency care deci-
sion-making is the potential and seldom understood
tension between the need to manage urgency and also
severity or complexity—stemming largely from the need
not only to treat urgent conditions, but to categorize
patients according to whether they need inpatient
admission or can be discharged from the ED. Work
pressure is evident in the relatively large amount of
time, during the observations, registrars appeared to
spend with patients in triage categories 3 and 4 com-
pared with patients in other triage categories. Patients
in lower triage categories might potentially be even
more severely sick than patients in higher triage cate-
gories. Emergency clinicians focus on whether the
patient requires inpatient admission or whether the
patient’s condition can be diagnosed and fully treated,
allowing discharge directly from the ED. This might be
called the ‘‘admission–discharge conjunction.’’ The tran-
scripts of medical ward rounds show that the chal-
lenges of treating patients in triage categories 3 and 4,
Nugus et al. • WORK PRESSURE AND PATIENT FLOW MANAGEMENT
in particular—the attempt to prevent both their inpa-
tient admission and their re-presentation to the
ED—represents an underrecognized aspect of the com-
plexity of ED work which emergency clinicians actively
manage and is central to the dynamics of ED flow.
Strategy 2—Managing Patient Flow
Emergency departments have a limited number of sec-
tions and beds that can be used at one time. When the
maximum capacity is reached, there is increased pres-
sure and less control of the effect of patient flow. Emer-
gency clinicians articulated this concept by expressing
a desire to gain control over department flow. The
importance of feeling in control was conveyed in the
superstition of avoiding saying the ‘‘q’’ word (‘‘quiet’’)
for fear of ‘‘jinxing’’ the department and attracting an
onslaught of complex patients (e.g., Junior nurse,
Hospital A, Shift 2, p. 4). This was used humorously on
occasion, but it is interesting that people steeped in
medical and nursing science have recourse to such
anthropomorphic language and treat the department as
a living, breathing organism. A registrar, two staff spe-
cialists, and a senior nurse, on separate occasions, used
remarkably similar language to express how desirable
but difficult it was to reduce work pressure by gaining
control of the motion of the ED. They are using the
agential term ‘‘I’’ to gain control of ‘‘it,’’ which is
departmental flow:
Registrar: ‘‘Once it’s out of control it’s hard to get
back …’’ (Junior doctor, Hospital A, Shift 1, p. 26).
Staff specialist: ‘‘I find at about the half-way mark
I’ve got to get on top of it or it’ll run away …’’
(Senior doctor, Hospital B, Shift 1, p. 29).
Staff specialist: ‘‘I find when it’s out of control it’s
hard to get it back under control—like when seeing
patients in the [ambulance] bay’’ (Senior doctor,
Hospital B, Shift 2, p. 24).
Staff specialist: ‘‘Mmm. It was under control this
morning but I keep getting side-tracked. I need to
pull it back …’’ (Senior doctor, Hospital A, Shift 2,
p. 36).
Nursing team coordinator: ‘‘It’s starting to go feral
now [curses]. It was traveling nicely. It’s really hard
to get it back under control’’ (Nursing Team Coor-
dinator, Hospital B, Shift 2, p. 25).
Conversely, a nursing team coordinator said, with
delight: ‘‘It’s flowing nicely; all under control.’’ This
particular comment was surprising because on that
occasion, all beds were full. The field researcher asked
about this and the team coordinator said: ‘‘No, it’s more
about how it’s flowing’’ (Nursing Team Coordinator,
Hospital A, Shift 2, p. 11). Although patient flow cannot
necessarily be controlled, staff can mitigate the extent
of its effects on their work, that is, its ability to exert
pressure on them. The ED functions with an equilib-
rium of busyness that staff create; that is, it was rarely
quiet, usually busy, but always with the more senior
eyes scanning the ED, avoiding it becoming chaotic.
ACADEMIC EMERGENCY MEDICINE • October 2011, Vol. 18, No. 10 • www.aemj.org 1049

ESS 1: ‘‘I feel the same way you do.’’

Strategy 3—Managing the Boundaries Within the
ED
ESS 2: ‘‘You’re calling it gastro [gastroenteritis] and
Another dimension in the patient flow process involved
I’m calling it appendicitis. I think that’s the beauty
allocating patients to a particular geographic location
of EMU. It allows these things to reveal them-
in the ED. Generally, emergency clinicians allocated
selves.’’
patients to sections of the ED on the basis of the
urgency, acuity, and complexity of their conditions.
(Senior doctor, Hospital B, Shift 2, p. 27).
These were inextricably tied to decisions concerning
admission versus discharge, and to alleviating or pre- This exchange reflects the relative boundedness of
venting work pressure, following initial diagnosis and the EMU from the rest of the sections even though they
treatment of their conditions. In general, the most are all parts of the ED. Allocation of patients to the
urgently and acutely ill patients were assigned to the EMU was an adaptive strategy, balancing various needs
resuscitation bays. Patients were assigned to the follow- for optimal patient flow.
ing other sections of the ED in descending order of
urgency, complexity, and acuity: resuscitation bays,
Strategy 4—Managing Time in the Diagnostic, Test
acute section, subacute section, consulting rooms, and
Ordering, and Treatment Processes
the emergency medical unit (EMU).
ED clinicians also managed patients’ trajectories to
As a response to (or to prevent) work pressure, nurs-
reduce work pressure in patient flow. They were always
ing team coordinators sought to manage the workload
concerned to determine a diagnosis on the basis of a
of other nurses by taking into account the need to keep
patient’s history, physical examination, and investiga-
beds in particular sections of the ED for future need,
tion results. There were particular ‘‘pathways’’ attached
the skill mix of staff, and the recency with which a
to particular diagnoses, in terms of clinical treatment
patient had been received into a particular section of
and transfer to particular inpatient departments or for
the ED. If there were no patients being resuscitated,
discharge. The progress of pathways enabled by a diag-
one or two acute patients might, on rare occasions, be
nosis made it an important tool for emergency clini-
transferred from triage directly to a resuscitation bay to
cians to reduce work pressure by gaining some control
balance the workload between nurses allocated to the
over patient flow.
resuscitation bays and the nurses rostered onto the
More broadly, emergency clinicians had to manage
acute section.
their time. In managing patient trajectories, it was
The role of the EMU highlights the active agency of
clear that emergency clinicians execute two tasks in
ED staff to manage patient flow and reduce work pres-
relation to time: they do and they wait. Both involve
sure precisely because it functions as a type of inpatient
strategic decisions about time. Variables they can con-
ward within the ED. Patients were allocated to the EMU,
trol to reduce work pressure include: examining the
which functions as a short-stay or observation unit, by
patient; treating the patient with fluids, medication,
emergency specialists if they had a defined problem
and procedures; performing bedside tests and x-rays;
requiring a short period of intervention with the expec-
sending blood samples to the laboratory; and order-
tation that they will be suitable for discharge within
ing x-rays and computed tomography (CT) scans to
24 hours, were awaiting definitive investigations that
be performed in the radiology department. Variables
were likely to culminate in their discharge for a period of
they cannot control to reduce work pressure include:
observation to ‘‘declare’’ themselves, or if they were
waiting for symptoms or responses to treatment to
awaiting allied health review regarding their mobility.
continue to manifest themselves; time spent waiting
To this extent, the EMU functioned as a pressure
for test results; the time until x-rays and CTs were
valve. Its capacity to create breathing space made it a
undertaken; and the time waiting for doctors from
precious resource. More experienced nursing staff
inpatient teams to respond to the requests of emer-
worked in the acute section of the ED and less experi-
gency physicians to become involved in the care of a
enced, often contracted, staff were allocated to work in
patient. ED work required emergency clinicians to act
the EMU where the patients were more stable. The
or otherwise go into a holding pattern as part of
EMUs of both EDs differed from other sections of the
managing their time across multiple patients to
EDs in that the handovers from emergency nurses to
optimize flow.
their colleagues in the EMUs were more formal than
Emergency physicians sought to reduce work pres-
across other sections in the ED, and they were quiet
sure by avoiding unnecessary tests to diagnose a
and dimly lit. Thus, they also physically mirrored inpa-
patient’s condition, obliging them to undertake only
tient wards as distinguished from the continual and
those tests necessary to confirm or exclude important
inherent motion, bright lights, and noise that character-
diagnoses. The diagnosis itself was an important
ized sections of the EDs. Two staff specialists elabo-
moment for reducing work pressure in the trajectory
rated on the EMU’s role and significance:
of the ED patient, because once affected, it placed
[Emergency staff specialist (ESS)] 1: ‘‘… The sur- the patients on pathways of treatment corresponding
geon was great. If [she deteriorates] he’s happy to with particular diagnoses. Crucially, the diagnosis did
be called.’’ not merely emerge; it was an active, agential process.
For instance, during a ward round, a staff special-
ESS 2: ‘‘I thought they were compelling signs. If ist suggested to interns, residents, and registrars
that’s not compelling, I don’t know what is.’’ present:
1050
‘‘If you look, you always find something …
I remember when I used to learn a new condition,
I’d diagnose it weekly.’’ (Senior doctor, Hospital A,
Shift 2, pp.10, 13).
Awareness of the dynamics of diagnosis allowed
senior clinicians, in particular, some control over the
effects of patient flow. In essence, diagnoses were
actively used to reduce work pressure, demonstrating
clinicians’ active, if tacit, attempt to control patient
flow.
Strategy 5—Managing External Relations
Emergency clinicians manage work pressure by man-
aging the porous boundaries of the ED, that is, its
interaction with the immediate environment. These
activities concern engagement primarily with other
departments in the hospital, ambulance services, com-
munity health services, and primary care providers,
including family doctors (known as general practi-
tioners, or GPs, in Australia). There were complex
questions as to whether to discharge a patient or admit
him or her as an inpatient within the hospital. This
often led to a negotiation either with particular inpa-
tient teams for admission or with community health or
social service agencies and family doctors for dis-
charge. Ultimately there was a decision needed to
transfer or discharge, such as physically transferring a
patient to a hospital ward or requesting an orderly to
do so. This is evident in the following excerpt from a
medical ward round:
[Moved to 8] … Reg: ‘‘This is [patient’s name]. She’s
65 years old … neuro [neurological] condition …
supra pubic catheter … nitrates … She was going
to be discharged with [Hospital in the Home] but
no community services were arranged. Seen by
physio.’’ Staff specialist 1: ‘‘Nothing’ll change in
24 hours. Mobility issues?’’ Reg: ‘‘She’s been in a
nursing home.’’ Staff specialist 2: ‘‘Should come in
under neuro’’ [neurology]. Staff specialist 1: ‘‘Who
were they in under before?’’ Reg: ‘‘Urology.’’ Staff
specialist 1: ‘‘Better under Aged Care. I’m happy to
talk to one of the consultants directly …’’ (Senior
doctor, Hospital A, Shift 2, pp.14–15).
Interdepartmental dynamics were unavoidably a cen-
tral aspect of reducing work pressure by maintaining
or enhancing departmental flow. Often emergency phy-
sicians provided a diagnosis and provided the full
course of treatment and discharged patients directly
from the ED. The primary goal appeared to be to avoid
unnecessary hospital admissions.
Emergency physicians frequently liaised with physi-
cians from inpatient teams to admit the patient under
the care of their team, to request them to review a
patient (with a possibility of admission) or, less
frequently, to seek advice in confirming a discharge
decision. During the fieldwork period, more than 30%
of patients allocated triage categories 3 and 4 were
eventually admitted as hospital inpatients. Interdepart-
mental and interorganizational liaison was inextricably
bound up in maintaining the flow of patients, whether
it was for admission or for discharge.
Nugus et al. • WORK PRESSURE AND PATIENT FLOW MANAGEMENT
LIMITATIONS
The ethnographic fieldwork was conducted by one
researcher, which may have led to observer bias. How-
ever, the fieldwork was prolonged and immersed and
involved highly purposive sampling of various staff,
places, and objects in the ED. This increases the validity
of the study and makes it likely that the results are
generalizable across the two departments. Further-
more, the field researcher documented all instances of
talk and action and indicated when action or talk was
missed. Further, that one person undertook the
field work makes it more likely that the data about clini-
cians in different roles were collected and analyzed
consistently.
Ethnography sacrifices breadth for depth. Having
been restricted to two sites in Australia, the work is
also limited in generalizability. Further research might
apply these methods to EDs in other Australian states
and internationally. On the other hand, deep ethnogra-
phy (such as undertaking 1 full year of observation)
taps into worldwide cultures of particular communities,
such as international communities of emergency physi-
cians and emergency nurses. As far as roles are con-
cerned, from a sociological point of view, people share
more commonalities than differences.36 One validation
test is whether clinicians and researchers familiar with
EDs recognize the trajectories, flows of activity, and
core aspects of their work described here. In discussion
following presentations of these findings in various
parts of Australia, the United States, Canada, and
Europe, clinicians and researchers have reported a high
degree of resonance with these themes.
DISCUSSION AND CONCLUSIONS
This hypothesis-generating study contributes an
anthropological perspective on ED work. This provides
an empirical foundation, uniquely discernible through
qualitative research, about aspects of ED work that
hitherto have been the subject only of discussion or
commentary articles. It conveyed the interdependence
of active staff agency, whereby emergency clinicians
seek to provide the greatest good for the greatest num-
ber of patients, within resource limitations (such as
space, time, and staffing). Ensuring the safe discharge
and preventing re-presentation to the ED of all patients,
especially those in triage categories 3, 4, and 5, is an
important function both for patients and in saving the
resources of the health system. Our study upholds pre-
vious literature elaborating the tension between
urgency and complexity19 and extends understanding
of the management of this tension. Urgency and com-
plexity often but not always overlap, and their reconcili-
ation is testimony to the active agency of individuals
with a system of care, seldom accounted for in mea-
sures of ED performance.8 Emergency clinicians’ com-
munal attention is permanently fixed on the system: it is
a kind of ‘‘collectively mindful trajectory management.’’
There is a strong expectation that the patient will, if
possible, be treated and discharged home efficiently
from the ED—what might be called the ‘‘open-ended
discharge imperative’’—which begins at initial presenta-
ACADEMIC EMERGENCY MEDICINE • October 2011, Vol. 18, No. 10
tion. Effective and proficient transfer are ultimate goals
for patients and staff alike.
Reflecting the permeability of the ED’s boundaries
and its relationship to the external environment, the
motion of the patient trajectory does not start and end
in the ED.26,41 Emergency clinicians work with the com-
plexity of patient flow as a response to patients arriv-
ing, constituting a unidirectional flow from which
patients are either discharged from the ED or physi-
cally transferred to other departments in the hospital.
There are three implications of this study. First, the
indispensible intertwining of clinical and organizational
work of emergency clinicians might suggest that emer-
gency physicians and nurses receive more systematic
training in the way care is organized, how to communi-
cate, and about external negotiation, from a dynamic
systems point of view. Second, the complexity of ED
work suggests that accountability for ED patient flow
ought to reside in the whole hospital, or the wider
health system, in addition to the ED. Furthermore,
organizational, financial, and quality indicators can deli-
ver more efficacious measures of ED performance than
efficiency measures alone. Third, practical intervention
to enhance patient flow and reduce work pressure
relies on understanding the problem. Our study and its
five findings point to the following hypothesis to be
tested: that patient flow is associated with work pres-
sure, as measured by self-reported staff pressure (dur-
ing overcrowding compared with optimal flow), and
departmental capacity. Patient flow relates to cycles of
variation in numbers and skills of staff, numbers and
conditions of patients, and hospital and ED bed capac-
ity. The findings delivered by this study can feed into
dynamic models that simulate the work of emergency
clinicians as a way of testing system interventions with-
out adverse consequences.42 Future research involves
testing the five outcomes using systems dynamic
modeling techniques.
References
1. Demerouti E, Bakker AB, Bulters J. The loss spiral
of work pressure, work-home interference and
exhaustion: reciprocal relations in a three-wave
study. J Vocat Behav. 2004; 61:131–49.
2. Crouter AC, Bumpus MF. Linking parents’ work
stress to children’s and adolescents’ psychological
adjustment. Curr Dir Psychol Sci. 2001; 10:156–9.
3. Günal MM, Pidd M. Understanding target-driven
action in emergency department performance simu-
lation. Emerg Med J. 2009; 26:724–7.
4. Lane DC, Monefeldt C, Rosenhead JV. Looking in
the wrong place for healthcare improvements: a
system dynamics study of an accident and emer-
gency department. J Oper Res Soc. 2000; 51:518–
31.
5. Wiinamaki A, Dronzek R. Using simulation in the
architectural concept phase of an emergency
department design. Proc Wint Simul Conf. 2003;
2:1912–6.
6. Dodier N, Camus A. Openness and specialisation:
dealing with patients in a hospital emergency
setting. Soc Health Ill. 1998; 20:413–44.
• www.aemj.org 1051
7. Nugus P, Bridges J, Braithwaite J. Selling patients.
Br Med J. 2009; 339:b5201.
8. Nugus P, Braithwaite J. The dynamic interaction of
quality and efficiency in the emergency department:
squaring the circle? Soc Sci Med. 2010; 70:511–7.
9. Vassy C. Categorisation and micro-rationing: access
to care in a French emergency department. Soc
Health Ill. 2001; 23:615–32.
10. Miró Ò, Sanchez M, Espinosa G, Coll-Vinent B,
Bragulat E, Millá J. Analysis of patient flow in the
emergency department and the effect of an exten-
sive reorganization. Emerg Med J. 2003; 20:143–8.
11. Derlet R, Richards T. Overcrowding in the nation’s
emergency departments: complex causes and dis-
turbing effects. Ann Emerg Med. 2000; 35:63–8.
12. Holroyd BR, Bullard MJ, Latoszek K, et al. Impact
of a triage liaison physician on emergency
department overcrowding and throughput: a ran-
domized controlled trial. Acad Emerg Med. 2007;
14:702–8.
13. Richardson DB, Mountain D. Myths and facts in
emergency department overcrowding and hospital
access block. Med J Aust. 2009; 190:369–74.
14. Diercks DB, Roe M, Peacock WF, et al. Prolonged
emergency department length of stay is associated
with worse guideline compliance and increased
adverse events [abstract]. Ann Emerg Med. 2006;
48:29.
15. Hendrie J, Sammartino L, Silvapulle MJ, Braitberg
G. Experience in adverse event detection in an
emergency department: nature of events. Emerg
Med Australas. 2007; 19:9–15.
16. Richardson D, Bryant M, Kelly AM. Improvement in
efficiency with patient streaming [abstract]. Emerg
Med Australas. 2005; 18(Suppl 1):A10.
17. Sprivulis P. Pilot study of metropolitan emergency
department workload complexity. Emerg Med
Australas. 2004; 16:59–64.
18. Fernandes CMB, Bouthillette F, Raboud JM, et al.
Violence in the emergency department: a survey of
health care workers. Can Med Assoc J. 1999;
161:1245–8.
19. Liu S, Hobgood C, Brice JH. Impact of critical bed
status on emergency department patient flow and
overcrowding. Acad Emerg Med. 2003; 10:382–5.
20. Ieraci S, Digiusto E, Sonntag P, Dann L, Fox D.
Streaming by case complexity: evaluation of a
model for emergency department fast track. Emerg
Med Australas. 2008; 20:241–9.
21. Nugus P, Forero R. Understanding interdepartmen-
tal and organizational work in the emergency
department: an ethnographic approach. Int Emerg
Nurs. 2011; 19:69–74.
22. Braithwaite J. An empirical assessment of social
structural and cultural change in clinical director-
ates. Health Care Anal. 2006; 14:185–93.
23. Braithwaite J. Analysing structural and cultural
change in acute settings using a Giddens-Weick
paradigmatic approach. Health Care Analysis. 2006;
14:91–102.
24. Lingberg E. Managing complexity: acknowledge the
attraction patterns by supporting sensemaking and
allowing the quality system to serve as the panoptic
1052 Nugus et al.
system. Int J Health Care Qual Assur. 2002; 15:
213–6.
25. Montuori LA. Organizational longevity: integrating
systems thinking, learning and conceptual complex-
ity. J Organiz Change Man. 2000; 13:61–73.
26. Nugus P, Carroll K, Hewett DG, Short A, Forero R,
Braithwaite J. Integrated care in the emergency
department: a complex adaptive systems perspec-
tive. Soc Sci Med; 71:1997–20040.
27. Behrens TR, Foster-Fishman PG. Developing oper-
ating principles for systems change. American J
Com Psych. 2007; 39:411–4.
28. Plsek PE, Greenhalgh T. The challenge of complex-
ity in health care. BMJ. 2001; 323:625–8.
29. Fitzgerald G, Jelinek G, Scott D, Gertz M. Emer-
gency department triage revisited. Emerg Med J.
2010; 27:86–92.
30. Tan J, Wen HJ, Awad N. Health care and services
delivery systems as complex adaptive systems:
examining chaos theory in action. Comm ACM.
2005; 48:36–44.
31. Bennett S, Plint A, Clifford TJ. Burnout, psychologi-
cal morbidity, job satisfaction, and stress: a survey
of Canadian hospital based child protection profes-
sionals. Arch Dis Child. 2005; 90:1112–6.
32. Morrison WE, Haas EC, Shaffner DH, Garrett
ES, Fackler JC. Noise, stress and annoyance in a
pediatric intensive care unit. Crit Care Med. 2003;
31:113–9.
33. Nyssen AS, Hansez I, Baele P, Lamy M, DeKeyser
D. Occupational stress and burnout in anaesthesia.
Brit J Anaesth. 2003; 90:333–7.
• WORK PRESSURE AND PATIENT FLOW MANAGEMENT
34. Weinberg A, Creed F. Stress and psychiatric disor-
der in health and hospital staff. Lancet. 2000;
355:533–7.
35. Spradley JP. Participant Observation. New York,
NY: Holt, Rinehart & Winston, 1980.
36. Nugus P. The interactionist self and grounded
research: reflexivity in a study of emergency depart-
ment clinicians. Qual Sociol Rev. 2008; 4:189–204.
37. Tesch R. Qualitative Research: Analysis Types and
Software Tools. New York, NY: Falmer Press, 1990.
38. Charmaz K. Grounded theory: objectivist and con-
structivist methods. In: Denzin NZ, Lincoln YS (eds).
Handbook of Qualitative Research. Thousand Oaks,
CA: Sage, 2000, pp 506–36.
39. Glaser BG. Basics of Grounded Theory Analysis:
Emergence versus Forcing. Mill Valley, CA: Sociol-
ogy Press, 1992.
40. Nugus P, Greenfield D, Travagalia J, Westbrook J,
Braithwaite J. How and where clinicians exercise
power: interprofessional relations in health care.
Soc Sci Med. 2010; 71:898–909.
41. Walters EH, Dawson DJ. Whole-of-hospital
response to admission access block: the need for a
clinical revolution. Med J Aust. 2009; 191:561–3.
42. Forsberg HH, Aronsson H, Keller C, Lindblad S.
Managing health care decisions and improvement
through simulation modeling. Q Manage Health
Care. 2011; 20:15–29.