1. Organizing Emergency Care: The Emergence of Emergency Physicians in The Netherlands Constanze D. Kathan & Marjolein A.G. van Offenbeek

2. 2 Research project Practical relevance: To evaluate the emergency physicians’ effects on the ECU organization and performance

3. 3 Emergency Physicians in NL Changes in patient demand (volume, diversity, complexity, demanded quality) Changes in labour supply (doctors’ scarcity, restructuring specialist training)  Emergency Physician (EP) History: 1999: First hospitals started a 3 years cross-specialty training 2005: ~ 20 fully trained EPs, another ~ 80 in training

4. 4 Theoretical Background Structural Contingency approach: Task environment - work structure - performance Questions: Will the more dynamic task environment drive the ECU towards a more organic work structure? Or will the higher input volume and task analyzability drive the ECU towards a more mechanistic structure? Will any of these two contextual changes override the effects of the other one?

5. 5 Expected Shift in Work Structure Low overlap in competencies High overlap in competencies High specialization Mechanistic Supple role division, mutually adjusted division of labor. Low specialization Organic Large teaching hospitals Small non-teaching hospitals

6. 6 Propositions I P1: Perceived opportunities for personal development at the ECU are higher for EPs than for residents. P2: The EPs’ permanent presence and their shared passion for emergency medicine result in employees’ higher commitment with the ECU than if staffed with residents (in teaching hospitals). P3: With EPs: A more flexible division of labor between the doctors and between nurses and doctors results in recognizing the work as more challenging.

7. 7 Propositions II P4: ECUs staffed with permanent EPs and emergency nurses experience a better team learning climate than those operating with alternating residents or temporary interns. P5: In ECUs with EPs higher interpersonal support and better interpersonal atmosphere is experienced than in those without EPs (in large teaching hospitals). P6: EPs’ permanent ECU presence and their assignment to routine tasks result in clearer work rules and role expectations.

8. 8 Method I Case selection - six cases: Large teaching hosp. Small non-teaching hosp. EPs are usedCase A, case BCase C EPs are not used Case D, case ECase F

9. 9 Method II Survey (8 working climate dimensions) Individual dimensions: Personal development, commitment, challenging job Organic dimensions: Team learning, interpersonal atmosphere, interpersonal support Mechanistic dimensions: Clarity of work rules, clarity of role expectations Interviews with ECU managers, EPs, nurses, secretaries, Observations

10. 10 Dimensions And Applied Scales Dimension N of items Cronbach’s α Variance explained by factor Personal development7.9063% Commitment6.8253% Challenging work5.6039% Team learning10.8950% Interp. atmosphere4.7458% Interpersonal support2.7379% Work rules3.6358% Role expectations3.6660%

11. 11 Results I With EPsWithout EPsT-test n=84n=91Not sig. Personal development 3.68 * 3.65Not sig. Commitment 3.96 * 3.71Sig. (p <.05) Challenging work 3.09 * 2.94Sig. (p <.05) Team learning 3.53 * 3.38Not sig. Interp. atmosphere 4.10 * 4.02Not sig. Interpersonal support 4.32 * 4.15Not sig. Work rules2.96 2.97 * Not sig. Role expectations4.144.23 * Not sig. * = score above mean

12. 12 Results II Interns ResidentsEPs T-test (EPs – Res.) No EPEPsNo EPEPs n =71014417 Personal development3.733.863.23.03.39Not sig. Commitment3.744.13.143.03.91Sig. (p <.01) Challenging work3.02.922.612.653.16Sig. (p <.01) Team learning3.533.573.223.13.44Not sig. Interp. atmosphere4.364.134.064.194.15Not sig. Interpersonal support4.144.03.713.754.32Sig. (p <.01) Work rules3.142.832.712.52.82Not sig. Role expectations4.714.074.384.584.12Not sig.

13. 13 Evidence for Propositions P1: Opportunities for personal development are higher for EPs than for residents. Some evidence found (t-test not significant) P2: Commitment of EPs is higher than the residents’ (in teaching hospitals). Supported P3: With EPs: work is more challenging for EPs and nurses. Supported P4: With EPs: team learning is higher. Some evidence found (t-test not significant) P5: With EPs: better interp. atmosphere and interp. support (in teaching hospitals). Results in expected direction (t-test not significant) P6: With EPs: clearer work rules and role expectations. Rejected Qual. evidence for possibility.

14. 14 Qualitative Evidence for Proposition 1 “We want to become recognized specialists. It’s still a long way and it’s going slowly and we have to prove again and again that we can do it better” (EP, case B). “In the beginning we had to overcome many obstacles. But we bring more expertise to the unit, therefore delivering better care for the patients. And that’s what it’s all about!” (EP, case A).

15. 15 Qualitative Evidence for Proposition 4 “Teambuilding and learning between nurses and doctors has increased. … We are ONE club. Of course there is still a difference between doctors and nurses because it is two different occupations. But we are one team and that is how we really experience it.” (EP, case C). “That [team learning] has something to do with the new occupation and also with the individuals. The EPs are team players. They are not as rigorously ambitious and Machiavellian as specialistic residents.” (nurse, case B). Where EPs are not used: “The nurses at the ECU may feel like a team. But the doctors have their true colleagues outside the ECU.” (specialist, case D).  Downbeat voice: “I do not regard the emergency nurses as my colleagues.” (EP, case A).

16. 16 Qualitative Evidence for Proposition 6 “With EPs, it is easier to come to agreements. Much more is done according to protocols. Nothing is left to chance any more.” (nurse, case B). “Together with the nurses, we [EPs] learnt what to expect from one another. Clear task allocations exist and everybody knows them. You don’t have to explain these rules anew every three months.” (EP, case C).  “Some fully trained EPs still regard themselves as residents. The EPs remit is not clear yet even within the NVSHA [Dutch association of emergency physicians].” (EP, case C). “The EPs want everything at once, but at a minimal cost price. That is not possible.” (nurse, case C).

17. 17 Trends in Shifting Work Structure Low overlap in competencies High overlap in competencies High specialization Mechanistic Supple role division, mutually adjusted division of labor. Low specialization Organic Large teaching hospitals Small non-teaching hospitals No observable trend (yet) No observable trend (besides work rules)

18. 18 Conclusions Limited statistical evidence. Most propositions rejected. May be explained by A coherent EP-system does not appear to exist (yet)  limited comparability of traditional system and “EP-system”. EPs need to work more independently with more responsibility in order to prove benefit. Still, qualitative and some quanititative evidence found that EPs are a promising development for better working climate. Large hospitals are able to gain more positive effects on working climate by using EPs than small ones.

19. 19 Discussion Does good working climate require continuity? New occupations do not just need new training systems. To achieve sustainability, it is important that the new occupation fits the organizational structure. To which extent should the organizational structure itself be adjusted as well?