International Emergency Nursing xxx (2014) xxx–xxx

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Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers Henrik Andersson RN, MSc, Lecturer, PhD Student a,b,⇑, Birgitta Wireklint Sundström RN, AN, PhD, Assistant Professor b, Kerstin Nilsson RN, PhD, Professor a, Eva Jakobsson Ung RN, PhD, Senior Lecturer, Assistant Professor a a b

University of Gothenburg, Sahlgrenska Academy, Institute of Health and Care Sciences, Göteborg, Sweden University of Borås, School of Health Sciences, Borås, Sweden

a r t i c l e

i n f o

Article history: Received 9 December 2013 Received in revised form 26 January 2014 Accepted 5 February 2014 Available online xxxx Keywords: Management Emergency Department Everyday work Emergency healthcare Qualitative content analysis

a b s t r a c t Introduction: Through their formal mandate, position and authority, managers are responsible for managing everyday work in Emergency Departments (EDs) as well as striving for excellence and dealing with the individual needs of practitioners and patients. The aim of the present study is to explore managers’ experiences of managing everyday work in Swedish EDs. Method: A qualitative and exploratory design has been used in this study. Seven managers were interviewed at two EDs. Data was analysed using qualitative content analysis with focus on latent content. Results: Managers experience everyday work in the ED as lifesaving work. One of the characteristics of their approach to everyday work is their capability for rapidly identifying patients with life-threatening conditions and for treating them accordingly. The practitioners are on stand-by in order to deal with unexpected situations. This implies having to spend time waiting for the physicians’ decisions. Management is characterised by a command and control approach. The managers experience difficulties in meeting the expectations of their staff. They strive to be proactive but instead they become reactive since the prevailing medical, bureaucratic and production-orientated systems constrain them. Conclusion: The managers demonstrate full compliance with the organisational systems. This threatens to reduce their freedom of action and influences the way they perform their managerial duties within and outside the EDs. Ó 2014 Elsevier Ltd. All rights reserved.

Introduction The assignment of Emergency Departments (EDs) is to provide safe emergency healthcare with a caring, cost-effective approach. This includes making assessments, diagnosing and providing treatment and caring, all within an acceptable timeframe in relation to the patients’ needs (The Swedish Code of Statues, 1982; Institute of Medicine, 2006). The managers in EDs, i.e. clinical managers (CMs), head nurses (HNs), deputy head nurses (DHNs) and healthcare developers (HDs) are responsible for leading and managing everyday work. In this study, everyday work means situations that occur regularly, without being outstanding or dramatic, and that are often related to non-urgent conditions of the patients. Through their formal mandate, position and authority, managers have varying

⇑ Corresponding author at: University of Borås, School of Health Sciences, SE-501 90 Borås, Sweden. Tel.: +46 33 435 47 45; fax: +46 33 435 44 46. E-mail address: [email protected] (H. Andersson).

degrees of responsibility for planning, budgeting, staffing, organising and controlling everyday work (Yukl, 2013). To fulfil the assignment of the ED successfully, managers are required to influence the practitioners’ understanding of the work of the ED and to motivate them to act in an agreed way (Yukl, 2013). In this study, practitioners are assistant nurses (ANs), registered nurses (RNs) and medical doctors (MDs). Swedish healthcare organisations seem to continue to be hierarchical and bureaucratic (Axelsson, 2000; Petterson, 2000; Carlström, 2012). The culture of hierarchy in the organisation is also visible in the distribution of work and power between professionals (Axelsson, 2000). Everyday work in EDs is dominated by medical work (Nyström, 2003; Chu and Hsu, 2011; Andersson et al., 2012), i.e. the MDs’ main field. Ways of influencing and motivating practitioners can differ depending on the individual manager’s leadership approach. Among several styles ‘transactional’ and ‘transformational’ leadership (Burns, 1978; Bass, 1985) are used to describe leadership approaches in different organisations. Transactional leadership focuses on job requirements and structures that clarify the

http://dx.doi.org/10.1016/j.ienj.2014.02.001 1755-599X/Ó 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001

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H. Andersson et al. / International Emergency Nursing xxx (2014) xxx–xxx

requirements and what the practitioner’s functions should be, based on communication between managers and practitioners. Practitioners are motivated by rewards and penalties. Transformational leadership focuses on inspiring practitioners to do more than is expected. The managers also mobilise commitment to goals and visions, encouraging creativity and innovation to find solutions to problems that arise, while at the same time providing intellectual stimulation and showing individual consideration (Bass et al., 2003). The managers’ capability to influence practitioners depends on what form of leadership approach they use (Cummings et al., 2008). According to Bass, managers commute between transactional and transformational leadership, depending on the situation and circumstances (Bass et al., 2003). Practitioners prefer managers who have a clear leadership style (Sellgren et al., 2006) and managers who have it experienced fewer problems in their management than managers with a composite leadership style (Lindholm et al., 2000). Managers who varied their leadership approach must also be understood in terms of a complex whole and the environment in which their leadership is practised. Everyday work at EDs consists of a variety of interactions between managers and practitioners. This leadership could therefore be understood as relational and thereby more transformational (Brower et al., 2000; Van Vactor, 2011). There are few studies relating to managers’ leadership performed in the context of the ED, especially when it comes to everyday work. Managers must have the capability of identifying how practitioners perform their work and how they are progressing, and be able to evaluate their work effort (Spivak et al., 2011). Managers’ behaviours have been found to have impact on work; both task- and employee-orientated leadership behaviours in the ED have a positive impact on RNs’ work satisfaction (Lin et al., 2011). Managers’ leadership style also influences the work. RNs’ turnover in EDs was found to be lower when managers used a transformational leadership style compared with use of non-transformational leadership (Raup, 2008). However, the learning of leadership skills in the ED is unplanned and therefore not comprehensive, resulting in a narrow perspective on what leadership means (Goldman et al., 2011). Managers’ responsibility for creating prerequisites for competence development in emergency nursing is an area that has been investigated and it has been shown that only a minority of managers consider that they have full responsibility for this (Andersson and Nilsson, 2009). In conclusion, the management of everyday work is challenging since managers need to strive for excellence and to deal with the individual needs of practitioners and patients. Knowledge about leadership in ED contexts remains limited and no studies concerning how managers lead and manage everyday work were found presenting the managers’ point of view. The aim of this study is to explore managers’ experiences of managing everyday work in Swedish EDs. Method Design As little is known about managers’ experiences of managing everyday work in EDs, a qualitative and exploratory design was selected. Qualitative design was undertaken to achieve better understanding of managers’ experiences related to the context and content in which everyday work is performed (Polit and Beck, 2012). Exploratory design was chosen because it is a way to discover new areas for research (Patton, 2002). To gain an understanding of managers’ experiences, data was collected through individual interviews. Setting This study was conducted in two EDs in Western Sweden. To enable there to be variation in managers’ descriptions concerning

their experience of managing everyday work, the selection criteria for these EDs were: (1) 24-h emergency healthcare provision, (2) access to internal medicine as well as surgical and orthopaedic specialities, (3) differences in the number of patients’ visits per year. Consequently, certain differences between the EDs gave rise to possible contextual nuances in this study. During the daytime, the first ED had MDs who were specialised in emergency medicine, while the second ED was staffed with medical doctors employed at other clinics who were not specialised in emergency medicine. Another difference was that the first ED had no DHNs or HDs. There were also differences in the number of patient visits per year (43,000 vs. 29,000) and the number of beds in the hospital (360 vs. 200). Participants The participants comprised seven managers: four female and three male and the age span was 40–52 years old. Six of the managers were nurses and one was a physician. The managers had spent more than 15 years in their professions. Six of them had worked as managers in EDs for less than five years. All managers except one were working full-time as managers, HDs were working part-time as RNs. HDs were included in the group of managers, although they did not belong formally to the linear hierarchical administrative order. HDs were included because they influence and provide support for managers leading everyday work in the ED. See Table 1 for further information about the managers. The inclusion criterion was a willingness to share their experiences of managing everyday work in EDs. The first author (HA) sent out a request for volunteers by e-mail and study information was included in the request. All managers agreed to participate in the study via e-mail reply. Data collection To achieve understanding, seven interviews were carried out. Before the interview commenced, the interviewer (HA) started with small talk to make the managers feel comfortable with the interview situation (Polit and Beck, 2012). The interviews were conducted in the form of a dialogue, i.e. a conversation based on a joint interest in the search for understanding and knowledge (Kvale, 2007), in this case managers’ experience of handling everyday work in EDs. The research question was: How do managers experience managing everyday work in EDs? The interview guide was based on the aim of the study (Kvale, 2007; Polit and Beck, 2012) and contained two main questions: What characterises everyday work and co-operation in the ED? What characterises your management and leadership in the ED? To ensure that the managers’ responses were perceived correctly, on-going clarifications were made. The interviews ended with the question: Is there anything else you’d like to mention? The clarification and closure question aimed at encouraging individual reflection to increase the richness and quality of the data. The interviews lasted 8.5 h in total, with an individual range of 47–93 min. Data analysis The first author transcribed the digitally-recorded interviews verbatim. The data was analysed using qualitative content analysis with focus on latent content, i.e. an analysis of what the text talks about involving an interpretation (Graneheim and Lundman, 2004). In the first step of the analysis, all the transcripts were read several times to gain a sense of the text as a whole. The focus was on determining what the text was about and interpreting the underlying meaning of the text. The second step, based on the aim of the study, was to identify units of meaning, such as words,

Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001

H. Andersson et al. / International Emergency Nursing xxx (2014) xxx–xxx Table 1 Overview of participants. n CMs HNs DHNs HDs

2 3 1 1

Gender Women Men

4 3

Age (years) Range Mean Professional group Nurse Medical doctor Years working in the profession (range) 31 Years working as a manager in an ED (range) 31

40–52 46.6 6 1 – – – – 4 2 1 3 3 1 – – – –

Managers: CMs – clinical managers, HNs – head nurses, DHNs – deputy head nurses, HDs – healthcare developers.

sentences or paragraphs. The condensed units of meaning were then labelled with codes. They were subsequently compared for differences and similarities and grouped into sub-themes, including descriptions close to the text. Finally, based on system thinking (Capra, 1996), the underlying meaning was interpreted and described in a main theme. In this study, system thinking is seen as a theoretical approach. System thinking is considered an appropriate means of gaining a holistic understanding of the management of everyday work (Capra, 2005). System thinking is a way to make possible the understanding of patterns, relationships, processes and contexts (Capra, 2005). This thinking is also an alternative to other theoretical frameworks that view managers, practitioners and technology as parts that exist around the patient. In contrast to this view, system thinking sees a relational network that keeps the parts together as a whole (Capra, 1996). Furthermore, an ED is viewed as a system with patients arriving and leaving. The emergency healthcare provided depends on the activities, structures, functions and interpersonal relationships in the ED (Capra, 1996), and their relationships with each other and with other systems outside the ED (Asplin et al., 2003). An ED is influenced by external environments, for example political decisions and financing, as well as by internal environments such as culture (Capra, 1996) and the managerial system at the hospital (Chaffee and McNeill, 2007). To ensure trustworthiness, the authors first read and reflected on the text independently and then the research team discussed their reflections on the codes, sub-themes and theme. In the analysis process, the authors’ pre-understanding of management in EDs was discussed in order to make the basis for interpretation of the interviews explicit. To underline the authenticity of their interpretations, a number of quotations are presented. The quotations are coded by

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bracketed numbers in order to safeguard the participants’ integrity, together with a presentation of the results. For an example of the analysis process, see Table 2. Ethics It is important to expose managers’ experiences of managing everyday work in EDs to research since few studies have been carried out. Simultaneously, this can be a sensitive issue as it may uncover weaknesses among managers in their ways of leading and managing everyday work. All managers received a letter of information about the study together with a consent form. The managers participating gave their informed consent. They were each given an identification number to ensure confidentiality. The Regional Ethics Committee in Gothenburg (Ref. 639-08) approved the study. Results The managers’ experiences of everyday work in Swedish EDs and their management are described in a main theme Constrained by the systems with three additional sub-themes: Maintaining and securing the patient’s vital status while waiting for the doctor’s decision, Command and control with a circumscribed manager mandate and Leading everyday work with difficulty in meeting expectations. Constrained by the systems The main interpretation is that managers’ managerial work in EDs involves expectations that they will facilitate the provision of medical emergency healthcare, predominantly to patients with emergency and life-threatening conditions, and also that they will ensure cost efficiency and productivity gains. However, managers are also responsible for all patients attending EDs, irrespective of the degree of urgency in a patient’s condition, and this includes non-urgent patients. To fulfil the assignment of the EDs, everyday work is monitored by means of bureaucratic forms of control. Managers have an important part to play in this control system. They are responsible for monitoring everyday work performed in EDs and ensuring its correctness and efficiency. However, managers are themselves also subjected to screening. ‘‘... Our hospital director has a lot of control over our business and you feel very monitored’’ (6) Managers of EDs have power through their formal mandate. However, they are expected to comply with the systems that control EDs, which means that their power is not utilised. Instead, managers choose to hold back their personal values, preferences, visions and aspirations and to adapt to the systems. Compliance with the systems means that the managers are constrained by the systems. A consequence of the above is that managers perceive EDs as an emergency response organisation. This explains why emergency healthcare in EDs focuses on unexpected, dramatic emergency medical conditions. These take precedence over other patients’ caring needs. Another consequence is that teamwork in EDs focuses on efficiency and productivity gains e.g. reduced lead times, by streamlining the care and treatment processes in EDs. Compliance with the systems is a form of behaviour that involves loyalty to a top-down management system, resulting in appreciation and acceptance by superior managers. Through compliance, managers become part of a managers’ group. However, the price managers pay for this access is limited freedom of action, which influences their capacity to develop everyday work.

Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001

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H. Andersson et al. / International Emergency Nursing xxx (2014) xxx–xxx

Table 2 Examples of an analysis process. Unit of meaning

Condensed unit of meaning

Code

Sub-themes

Main theme

It is awesome to work in an Emergency Department. A lot of things happen That’s how you influence. I control the work and I write job instructions I do not work with practical care very much. There’s not enough time

In an Emergency Department a lot of things happen I control the work, I write job instructions Don’t work much in practical care; not enough time

Varying work Instructions

Maintaining and securing the patient’s vital status while waiting for the doctor’s decision Command and control with a circumscribed manager mandate Leading everyday work with difficulty in meeting expectations

Constrained by the systems

Lack of relationships

‘‘... I thought when I started [as a manager] that I would be able to develop the work [but]. . .I am very limited by finances, structure and organisation’’ (6) Managers strive to be proactive but they become reactive as they are constrained by the systems. They choose to adapt to the prevailing order because adaptation is necessary to maintain their position as managers in the ED. Fig. 1 presents an overview of the results. Maintaining and securing the patient’s vital status while waiting for the doctor’s decision This sub-theme emerged from managers’ experiences of everyday work in EDs. Managers relate that everyday work is determined by the large number of patients attending the EDs and by the practitioners’ brief, rapid encounters with those patients. They also state that everyday work is influenced by the requirement to provide emergency healthcare, which is in turn affected by the limited resources allocated to the EDs. According to the managers, these conditions mean that practitioners need to handle everyday work situations irrespective of the actual circumstances. The fluctuations of everyday work create uncertainty and occasionally lead to chaotic situations. ‘‘[There] is extensive variation in the work, from being very calm to something happening ... the patient’s condition may change [and] this makes the ED very special’’ (5) One description of everyday work is that it is ‘lifesaving work’. This requires a capacity for the rapid identification and treatment of patients with emergency and life-threatening conditions. All patients pass through triage, where emergency and life-threatening conditions are sorted out from non-life-threatening signs and symptoms. In triage, medical assessments are made and patients are prioritised. At the same time, managers describe their frustration that RNs are incapable of quickly recognising what is important in triage assessment. ‘‘...you cannot interview a person for twenty minutes, there’s no time for that ... you have to extract what is essential and structure it’’ (1) This inability is time-consuming as the queue of non-assessed patients for triage increases alongside reduced patient throughput. Managers held the view that it is the number of patients and their condition that determine how much time practitioners devote to each patient. Managers said that there is a tradition in the EDs of focusing on emergency and life-threatening conditions. Managers also relate that actions designed to satisfy caring needs, such as instilling confidence and providing information to the patients, are of no interest. ‘‘To be taken care of and given an explanation ... why they have to wait or how long the waiting time is. . . there’s no time for that. Medical action comes first’’ (3)

Another predominant description of everyday work is ‘standby’, which means being prepared for unexpected situations among patients in the ED. To avoid unexpected situations, monitoring and staff rounds take place regularly throughout the patient’s stay in the ED. Managers describe monitoring as focusing on the identification of medical needs, which is important for patients waiting for a medical decision, and staff rounds are a way of identifying caring needs. This ‘stand-by’ state in everyday work requires a co-ordinator to oversee the situation. Managers also said that the co-ordinator needs to have clearly defined responsibility for organising and leading practical, everyday work. ‘‘. . .we have so many patients ... who require flexibility ... [someone] to manage and sort the information. . .’’ (2) ‘Waiting for decisions’ is the third description of the everyday work at the EDs. Managers state that decision-making in EDs is organised hierarchically and consists mainly of medical decisions made by MDs. There is an element of uncertainty in the MDs’ decision-making. This is particularly evident when it comes to deciding whether to send the patient home or not. ‘‘. . .they [MDs] dare not send patients home or admit them without being absolutely sure that they have a diagnosis’’ (4) The managers held the view that this uncertainty results in comprehensive and extended diagnostic examinations, such as blood tests and X-rays. This in turn increases the patient waiting time in the EDs. Command and control with a circumscribed manager mandate This sub-theme relates to managers’ experiences of management in EDs. The managers held the view that the EDs are part of a hierarchical healthcare system and command and control of the EDs rests with the politicians and the hospital director. The managers of the EDs are responsible for organising, implementing, monitoring and reporting a given task within a specified period. The managers state that their primary assignment is to focus on improving efficiency at EDs through, for example, resource utilisation and throughput of patients. The managers’ assignment is described in detail, thus limiting their possibilities of influencing the way the assignment is designed. ‘‘... we are regulated in detail. . . the hospital director tells me what to do. It is stated very clearly’’ (6) The managers describe that they are expected to make changes to and develop everyday work continuously in line with the assignments stipulated in the operational plan determined by the hospital. Meeting the challenges presented by developmental work is time-consuming, which makes it problematic for the managers. There is ‘change fatigue’ as the recovery time between changes is limited.

Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001

H. Andersson et al. / International Emergency Nursing xxx (2014) xxx–xxx

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Fig. 1. How managers describe management of everyday work at Swedish EDs.

‘‘. . .we expect that when we have made our changes, we can relax for a while but we can’t. Changes take place all the time’’ (2) The assignment of the EDs includes the demand for efficiency and a balanced budget. The managers said that there is an imbalance between available financial resources and the task of providing emergency healthcare based on patients’ needs. A balanced budget takes preference. Reducing staff costs is an example of measures managers employ to balance the budget and is a factor giving rise to frustration. This management method to balance the budget is used despite awareness of the negative impact of downsizing on workload, the potential to perform tasks and patient safety. ‘‘...we are understaffed in relation to the number of patients. It’s not surprising that things [work] go wrong’’ (3) Managers point out that there is ‘short-termism’ in approaching the assignment of providing emergency healthcare. They state that the implementation of the assignments of EDs requires an annual operating plan and protocols for managing everyday work. The managers said that the written annual operating plan contains objectives and the approaches and resources allocated to achieve those objectives as well as guidelines for evaluating outcomes. The annual operating plan is essential for planning and implementing the assignments during the year. It is mainly a plan for organising and solving problems here and now. The managers also held the view that visions for the future are absent. They describe this as a problem since the scope for adding new objectives to the plan is limited even if the objectives are important for the future. According to managers, another problem is that creating the plan is time-consuming and lack of time leads to its having deficiencies. Competence development strategies are an example of strategies that are not included.

Protocols specifying how certain tasks should be performed are essential in order to regulate practitioners’ responsibilities and authority in everyday work. Protocols are available and regulate, for example, medical assessments in triage and the medical and technical action that can be taken without a prescription from an MD. Managers describe these protocols as providing a common approach to everyday work and reducing waiting times for various medical procedures. However, the volume of protocols is constantly increasing and this affects the potential for establishing and assessing up-to-date protocols. Managers state that protocols constitute a detailed control system for everyday work, which affects the practitioners’ job satisfaction. This is something the managers cannot influence. ‘‘... in triage work you know what to do in this short space of time ... it has become so monotonous ... it’s constant ... many [practitioners] don’t feel the work is enjoyable’’ (1)

Leading everyday work with difficulty in meeting expectations This sub-theme was derived from managers’ experiences of leading everyday work in EDs. The managers describe the practitioners’ involvement in everyday work as being important. Supporting the practitioners’ growth and development is the responsibility of the managers. This support is necessary to enable practitioners to provide emergency healthcare in everyday work. This means that managers must be able to interpret and explain what the practitioners need to do, which in turn requires an understanding of the work of both practitioners and managers. Shared visions regarding workflow are important as they influence the practitioners’ way of understanding and managing

Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001

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H. Andersson et al. / International Emergency Nursing xxx (2014) xxx–xxx

everyday work. Performance improvement among practitioners is of particular importance. ‘‘. . .we are here to provide service to our patients; to make things as good as possible for them. After each shift, we reflect on what worked well and what didn’t and how we can do better tomorrow’’ (1) Managers describe problems regarding practitioners’ participation. For practitioners to become involved in everyday work, the managers need to be available to practitioners. However, managers also said that access to them is impeded, since the volume of administrative duties and responsibilities is overwhelming for them. Their different working schedules in relation to the practitioners are an additional aggravating factor. Managers try to explain why their involvement is an important part of everyday work. Even if the managers felt that access was adequate, they state that the practitioners felt it was too limited and criticised the managers for not being available. The managers state that they find it difficult to meet expectations. ‘‘... I am available five days a week between 8am and 8pm ... and receive [criticism] that I am not available sufficiently’’ (6) The managers held the view that co-operation and trust are important for carrying out the tasks and creating a workflow. Co-operation and trust allow practitioners to exercise shared decision-making. Managers describe the advantage of shared decisionmaking as being a reduced risk of misunderstanding between practitioners. Shared decision-making promotes productivity since practitioners do not need to spend time sorting out problems related to lack of communication. At the same time, managers state that there are problems regarding co-operation and trust. Practitioners have various organisational affiliations and this restricts the opportunity to remain updated on current procedures and working methods and to get to know each other. Managers also said that co-operation is characterised by hierarchical boundaries and a clear division of work between professional groups. They state that this is evident in the work of ANs and RNs. It is apparent when questions arise, e.g. Who should respond to the patients’ call for help? Who should assist the MDs in examinations? Who should take the next patient to triage? The attitude of ANs and RNs influences co-operation since ANs and RNs do not want to be seen as the MDs’ assistants. ‘‘Assisting the physician was not a good thing ... If the physician wants to do a rectoscopy, he or she can prepare for the examination.’’ (4)

Discussion This study shows that (1) managers regard the Swedish ED as a medical emergency response organisation and (2) that a bureaucratic, minutely controlled, production-orientated management system influences the management of everyday work. Managers regard the EDs as a medical emergency response organisation. The assignment of the EDs is to be prepared to provide emergency healthcare to patients with emergency or lifethreatening conditions. This is line with research by Nyström (2003) showing that emergency and lifesaving work has a prominent position and that the encounter between practitioners and patients is focused mainly on medical needs. However, the majority of the patients attending the EDs do not have a life-threatening condition (Tsai et al., 2010). This study is also in line with the practitioners’ view (Andersson et al., 2012). Everyday work forms the practitioners’ perspective, being characterised by rapid, short and standardised encounters (Andersson et al., 2012). Medical care

activities are in focus while individualised care is limited and difficult to provide in clinical practice (Andersson et al., 2012; Parke et al., 2013). This shared view of providing individualised care is a problem. Patients tend to experience themselves as ignored and abandoned because no one seems to care about them during their stay in the ED (Olofsson et al., 2012). This suggests that needs other than just medical needs must be met. Consequently, it is necessary to deviate from traditional patterns and hierarchies and instead develop everyday work in such a way that practitioners can deal with the need among patients for all forms of emergency healthcare. If managers are to fulfil the assignment of the EDs, they need to adopt an intertwined approach to medical and caring work that will necessitate calling into question certain aspects of their prominent position. EDs are characterised by a bureaucratic, minutely controlled, production-orientated management approach where it is the managers’ responsibility to effect a given task. The present study shows that standardisations, such as protocols, are valuable for managing routine-based everyday work, since they contribute to solving problems in a safe, orderly fashion. However, protocols can provide a false sense of security and belief that the work is being done in a certain way (Seddon, 2010). Previous research reveals problems associated with following protocols mindlessly or blindly without judging or considering whether this is appropriate in a particular situation (Ilott et al., 2006). Consequently, with such detailed control there is a risk that certain aspects of the patient’s needs will not be met if those needs are not regulated in the protocols. This study also shows that managers have a production-orientated approach with a focus on rapid emergency healthcare. Rapid emergency healthcare is important since it has an impact on admission to hospital and the risk of death (Guttmann et al., 2011). To provide rapid emergency healthcare, throughput improvements are necessary. However, it is important for managers to be aware of the risks associated with focusing on time and the impact this could have on the quality of the care provided. Data retrieved from standardised measurement systems are incomplete since the time for caring is not visible or measured (Melon et al., 2013). Finally, our findings show that there are constraints influencing the management of everyday work in EDs and the managers’ capability to fulfil the assignment of the EDs. These constraints create obstacles to meeting requirements, such as an imbalance between resources and emergency healthcare demands, a shortage of practitioners or a shortage of practitioners with adequate competencies. Dealing with different and sometimes conflicting demands requires managers to be adaptive, which implies that leaders must choose their approach (Yukl and Mahsud, 2010). However, management is difficult and it is easier for managers to be adaptable to external conditions and demands than to their own beliefs and values (Falkenström, 2012). Being constrained by the system therefore gives rise to the risk that managers might fail to demonstrate a capability to stand up for their own convictions and to have the courage to raise critical issues. The final issue is whether or not managers have the capability and the conditions for fulfilling the assignment of the ED. Strengths and limitations One limitation in the study is that only seven managers participated. This means that managers’ experiences of managing everyday work might lack variation. On the other hand, the strength of this study is that managers from different levels and from two different EDs are included and that the interviews resulted in extensive data in terms of rich, meaningful content. Another limitation is that the two EDs are organised in different ways. This could

Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001

H. Andersson et al. / International Emergency Nursing xxx (2014) xxx–xxx

influence managers’ descriptions of managing everyday work. Finally, this description only applies to the Swedish situation, and healthcare systems in other countries may be organised in other ways. The findings from this study can thus not be generalised, but the managers’ descriptions and the interpretation of managers’ experiences of managing everyday work in EDs have created a new understanding, which can be transferred to similar ED contexts. Conclusions This study shows that everyday work in EDs is characterised by preparedness for unpredictable situations, with a focus on emergency and life-threatening conditions and a workflow that provides rapid throughput. The management principles guiding managers in EDs are the budget and the detailed regulation of work. The managerial administration burden reduces the time available to a manager to lead practitioners in their everyday work. It is also important to take into account the fact that managers are governed by the implementation of the prevailing bureaucratic and production-orientated medical systems. To be accepted as a successful manager they are expected to follow management approaches that are inseparable from the system. At the same time, this threatens to reduce their freedom of action and their potential to exert an influence, both within and outside EDs. Our results suggest that managers can play a more active role in the development of everyday work to ensure that it takes into account the patients’ well-being and experiences and also that it focuses on the patients’ differing needs for emergency healthcare. Further research is required to understand the importance of contextual system factors when examining the way managers’ deal with everyday work in EDs. References Andersson, H., Nilsson, K., 2009. Questioning nursing competences in emergency health care. Journal of Emergency Nursing 35, 305–311. Andersson, H., Jakobsson, E., Furåker, C., Nilsson, K., 2012. The everyday work at a Swedish emergency department – the practitioners’ perspective. International Emergency Nursing 20, 58–68. Asplin, B.R., Magid, D.J., Rhodes, K.V., Solberg, L.I., Lurie, N., Camargo, C.A., 2003. A conceptual model of emergency department crowding. Annals of Emergency Medicine 42, 173–180. Axelsson, R., 2000. The organizational pendulum: healthcare management in Sweden 1865–1998. Scandinavian Journal of Public Health 28, 47. Bass, B.M., 1985. Leadership and Performance beyond Expectations. Free Press, New York. Bass, B.M., Avolio, B.J., Jung, D.I., Berson, Y., 2003. Predicting unit performance by assessing transformational and transactional leadership. Journal of Applied Psychology 88, 207–218. Brower, H., Schoorman, F., Tan, H., 2000. A model of relational leadership: the integration of trust and leader–member exchange. Leadership Quarterly 11, 227–250. Burns, J., 1978. Leadership. Harper and Row, New York. Capra, F., 1996. The Web of Life: A New Scientific Understanding of Living Systems. Anchor Books, New York. Capra, F., 2005. Complexity and Life. Theory, Culture & Society 22, 33–44. Carlström, E., 2012. Middle managers on the slide. Leadership in Health Services 25, 90–105. Chaffee, M., McNeill, M., 2007. A model of nursing as a complex adaptive system. Nursing Outlook 55, 232–241. Chu, W., Hsu, L., 2011. The process of acquiring practical knowledge by emergency nursing professionals in Taiwan: a phenomenological study. Journal of Emergency Nursing 37, 126–131.

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Please cite this article in press as: Andersson, H., et al. Management of everyday work in Emergency Departments – An exploratory study with Swedish Managers. Int. Emerg. Nurs. (2014), http://dx.doi.org/10.1016/j.ienj.2014.02.001