Conflict in emergency medicine: A systematic review.

BACKGROUND: The emergency department (ED) is a demanding and time-pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual-, team-, and systemic-level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research. METHODS: Online databases PubMed and Web of Science were systematically searched for relevant peer-reviewed journal articles in English with keywords relating to "conflict" and "emergency department," yielding a total of 29 articles. RESULTS: Narrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual-level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team-level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems-level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships. CONCLUSIONS: In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.

Evidence behind the exhortation? A rapid review of servant leadership's influence and claims in healthcare over the last decade.

Servant leadership is an other-oriented approach to leadership with multiple positive outcomes. However, its influence in the context of medicine, particularly on healthcare leaders, is less clear. We conducted a rapid review to examine the impact of servant leadership in healthcare over the last decade. We included a total of 28 articles, 26 of which described beneficial organisational, relational and personal outcomes of servant leadership. However, most of these were either conceptual or opinion-based articles. Moreover, most quantitative studies were cross-sectional, precluding causal inferences. Our review demonstrates that the purported positive association between servant leadership and healthcare outcomes lacks a strong evidence base. We conclude by calling for more rigorous empirical research to examine the effects and potential challenges of implementing servant leadership in healthcare contexts.

Are emergency departments leader identity workspaces? A qualitative study of emergency physicians.

OBJECTIVE: Emergency medicine is a discipline with complex leadership demands, which are experienced by junior and senior emergency physicians alike. In this environment, emergency physicians can struggle to work out what it means to be a leader and develop professional identities as leaders, necessitating a leader identity workspace. The aim of the present study is to explore whether emergency physicians view their work environment as leader identity workspaces. METHODS: An online qualitative survey was used that included open-ended questions about emergency physicians' experience of their workplace as a 'space' to craft their leadership identity. Participants' responses were analysed using reflexive thematic analysis. RESULTS: Three themes, comprising several subthemes, were identified that related to emergency physicians' ideal leader selves (leader dreams and desired leader selves), their experience of the community of clinicians in hospitals (confrontational sentient communities) and the types of rituals emergency physicians yearn for to support and legitimate their leadership (seeking vital leadership rites of passage). CONCLUSION: Our results suggest that neither EDs nor hospitals more generally exhibit the properties of, or are experienced by emergency physicians, as leader identity workspaces.

MONitoring Knockbacks in EmergencY (MONKEY) - An Audit of Disposition Outcomes in Emergency Patients with Rejected Admission Requests.

Background: Emergency Department (ED) clinicians commonly experience difficulties in referring patients to inpatient teams for hospital admission. There is limited literature reporting on patient outcomes following these complicated referrals, where ED requests for inpatient admission are rejected - which study investigators termed a "knockback". Purpose: To identify disposition outcomes and referral accuracy in ED patients whose admission referral was initially rejected. Secondary objectives were to identify additional patient, clinician and systemic factors associated with knockbacks. Selection and Methodology: Emergency clinicians prospectively nominated a convenience sample of patients identified as having knockbacks over two time periods (Jan-Feb 2020 and Aug 2020 to Jan 2021) at a tertiary Australian ED. Data were analyzed with a mixed-methods approach and subsequent descriptive and thematic analyses were performed. Results: A total of 109 patients were identified as knockbacks. The referrals were warranted, with 89.0% of cases (n = 97) ultimately requiring a hospital admission. In 60.6% (n = 66) of the admissions, patients were admitted under the inpatient team initially referred to by the ED, suggesting referrals were generally accurate. The number of in-hospital units involved in the admission process and ED length of stay were positively correlated (0.409, p < 0.001). Patient factors associated with knockbacks include pre-existing chronic medical conditions and presenting acutely unwell. Analysis of clinicians' perspectives yielded recurring themes of disagreements over admission destination and diagnostic uncertainty. Conclusion: In this patient sample, emergency referrals for admission were mostly warranted and accurate. Knockbacks increase ED length of stay and may adversely affect patient care. Further focused discussion and clearer referral guidelines between ED clinicians and their inpatient colleagues are required.

Reframing leadership: Leader identity challenges of the emergency physician.

Emergency medicine (EM) leadership is often conceptualised as either administrative leadership within the structure (e.g. head-of-committee leader) or operational/functional leadership within a group (e.g. resuscitation-scenario team leader). While these bases of identity are practically useful, they often do not take into account the intricate, underlying challenges to one's leader identity presented by the dynamic, fluid and transient context of EM leadership. In particular, emergency physicians face various leader identity challenges such as nonreciprocal leadership claims and grants at the interpersonal level, identity confusion with multiple roles at the intrapersonal level, tribalism at the team level and antithesis of identity workspace at the organisational level. The present paper proposes a reframing of EM leadership as a socially constructed identity process, whereby emergent leaders learn at the individual level to address identity challenges as they negotiate the nuances of leader-follower interactions. Similarly, at an organisational level, there is an opportunity for formal and emergent leaders to create psychologically safe identity workspaces. The co-creation of EM leadership by leaders and followers would help emergent leaders navigate their leader identity, allowing them to simultaneously inspire confidence and exert influence as future-fit health professionals and leaders.