Dr. Chris Luke says he profoundly wishes that all healthcare managers, and indeed politicians, would recognise the vital importance of including people’s feelings in management calculation and decision-making, as well as beds, budgets or other “resource” considerations.
When people ask me how I would “solve” the chaotic overcrowding in our emergency departments, my first impulse is usually to resort to anguished metaphor, arresting rhetoric or angry diatribe. Health economists from the 1980s, moral decay and counterfeit political promises are usually fingered, for a start. Invariably, however, I hark back to Oscar Wilde’s warning, to would-be visionaries: “If you want to tell people the truth, make them laugh, otherwise they’ll kill you.”
And there, in a nutshell, is the difficulty for those of us who seek to explain the seemingly intractable scenes of mass misery. It’s no laughing matter. Worse still, eyes routinely roll upwards when the subject is raised in social settings And yet, a quarter of the population of this country attend their local emergency department (ED) annually, so – comic or not – the question is of fundamental importance to those who manage the health service, and to the vast numbers of citizens who must endure an unexpected visit to hospital. Soon.
Any serious analysis of ED overcrowding must necessarily be complex, and rely on a firm grasp of sociological trajectories, trends in globalisation and population health statistics. And the remedies are equally challenging, based as they are on the intersection of (human) resources, economic cycles and public health interventions.
But I would offer a simpler solution. Or at least a first step in the process. Because I am utterly convinced that the most important contribution that someone like me – with 33 years’ experience at the healthcare frontline – can make is to draw attention to what I believe is the most neglected aspect of healthcare management: emotional intelligence.
I arrived at this perhaps surprising conclusion after years of studying management technique (as a trainee in the NHS) and actively micro-managing a variety of emergency departments in hospitals, both big and intimate. It seems to me that – of all the problems faced by the health service – it is the ones that follow a “misreading” of patients’ and staff feelings and – this is utterly crucial – their motivation, which have created our most entrenched crises. So here – for what it is worth – are the “ten therapeutic insights” which I believe are critical increments towards emotionally-intelligent management of emergency department overcrowding:
- Recognition of the main reasons why people become chronically and acutely ill or injured: the anxiety, loneliness, or buried grief which drive people to sugar, tobacco and a myriad anxiolytic intoxicants.
- Recognition that most people in the emergency department are actually there by choice: not always in the sense of “I fancy a trip to the ED today”, but in terms of the culmination of years of overdoing the sugar, salt, tobacco, alcohol, or recreational drugs inter alia.
- Acknowledgment that many people do in fact say to themselves, “the best thing for my ingrowing toe-nail/chronic skin disorder/long-term pain problem etc is to head to the emergency department” (because “although I may have to wait for hours, once I am registered there is a decent chance that I will be ‘plugged into the system’ and I will eventually get to see the relevant specialist sooner that I otherwise would”).
- Recognition that healthcare in the ED has become exponentially more complex: globalisation, our extended lifespan and technological possibilities mean that what can – and must – be done before patients get to a hospital ward is ever more challenging, from understanding dozens of patient languages to the technicalities of non-invasive ventilation for the breathless elderly, from the logistics of getting heart attack cases to a regional cardiac catheter lab to the vigilance required to contain exotic infections, life is far more convoluted in the ED than it was even a decade ago.
- Awareness that “difficulty makes people difficult” (poverty, chaotic drug dependence or daily exposure to violence means that victims themselves can be more than a little challenging).
- Appreciation that, when the ED gets crowded, people become angry and frightened and sometimes a little less cooperative.
- Understanding that being an emergency healthcare professional has become proportionately more demanding over the past quarter-century, with a now-relentless pressure on perennially overcrowded EDs, loss of the traditional “ebb and flow” in these units, and a requirement to acquire an almost limitless number of advanced skills (from intubation to lumbar puncture, by way of ventilation of the paralysed patient, casts, sutures, splints and umpteen ECG patterns), often out-of-hours at the doctors’ own expense, since last week’s announcements vis a vis the European Working Time Directive.
- Awareness that all the aforementioned makes working in the ED seem like a particularly egregious form of deliberate self-harm, meaning that many medical and nursing graduates actively avoid the pointy end of the hospital entirely, if they can, with financially and legally ruinous costs to the service in terms of shipping unknown locums in from all corners of the globe at dizzyingly short notice.
- Knowledge that the quality of all urgent care depends entirely on a dwindling band of the willing and the able.
- Certainty that the elderly lady on that trolley just over there desperately needs kindly, well-trained and enthusiastic nurses and doctors, with the time to care, and knowledge that they enjoy a rock-solid level of support at all times.
If these “elements” are at the forefront of readers’ minds when they go to work on a Monday morning, I think employees at their hospital can rest assured that they will be well managed.
That great man-manager Napoleon famously remarked that “courage is like love; it must have hope for nourishment.” Of course, he was right. Setting aside platitudes and political sales patter, it is people’s emotional needs (and the motivation which flows from these needs, and the way they are met or not) which are most commonly neglected by our “system”. And the result is often deep dissatisfaction, angry complaint and litigation on the part of our patients and their families and, equally importantly, levels of staff despondency, burnout and withdrawal which make high-quality healthcare so problematic.
The corollary is that, if we could address the various “incentives” (perverse and otherwise) which lead patients to the ED but drive staff away, we might finally begin to realise that banging our heads against the proverbial wall hasn’t worked to date, but changing our mind-set just might.
I profoundly wish that all healthcare managers, and indeed politicians, would recognise the vital role of emotional intelligence in healthcare particularly – in other words, the inclusion of people’s feelings in management calculation and decision-making, as well as beds, budgets or other “resource” considerations. Because motivation matters. It is what provides the reassuring smile, the glass of water and the chair, those elements of care which actually make all the difference. And just beyond them, lie such extraordinary gains in terms of efficiency, governance and reputation.
Dr. Chris Luke, Consultant in Emergency Medicine, Cork.
