• Roberto Forero, Sally McCarthy, Anna Holdgate, Jeffrey Braithwaite, Peter Nugus, and Margaret Fry.
• Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, Australia. p.nugus@unsw.edu.au
• Acad Emerg Med. 2011 Oct 1;18(10):1045-52.

ObjectivesIn this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding.MethodsAn 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.ResultsIn 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.ConclusionsTo 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, interacting 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.© 2011 by the Society for Academic Emergency Medicine.

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