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The role of the emergency physician at the
emergency department, role clarity and role
expectations and its influence on
collaboration.
Collaboration between emergency physicians and medical specialists.
Master’s Thesis Supply Chain Management University of Groningen
28-01-2019
By: Gijs Hoekstra Student number: S2529718 E-Mail: g.n.hoekstra@student.rug.nl
Supervisors: Prof. dr. J. T. van der Vaart MSc. R. Gifford
Co-assessor:Prof. dr. ir. CTB Ahaus
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Abstract
In this paper, the impact of role clarity on collaboration is measured. The setting is the emergency department (ED), where emergency physicians (EPs) collaborate with medical specialists in order to help patients go as well/safe and as fast as possible through the processes of the ED. In this research, the influence of the clarity of the role of the EP on this collaboration is investigated. Because the EP is a relatively new profession in the hospitals, the role of the EP might not be completely clear. Also, the role of the EP differs per hospital in the Netherlands. A single-case study at a hospital in the Netherlands is performed, where EPs and medical specialists are interviewed. Results show that the EPs and some of the medical specialists have a different view on what the EP’s most important tasks are. These differences in expectations about the role of the EP result in frustration and incomprehension about this role for both the EPs and the medical specialists and can be barriers for a good collaboration. Those differences are caused by an unclear role, due to unclear formal agreements, and because of a difference in opinion that the EP and the medical specialists have about the role of the EP. This paper contributes to the literature by explaining the clarity of the EP’s role at a Dutch ED and explains why there is a difference in expectations about the role of the EP in Dutch hospitals.
Keywords: Emergency physicians, medical specialists, role clarity, collaboration, emergency
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TABLE OF CONTENT
1. INTRODUCTION ...4 2. THEORY ...7 2.1 Patient flow ...7 2.2 Collaboration ...7 2.3 Role clarity...8 3. METHODOLOGY ... 113.1 Case selection and case description ... 11
3.2 The process of the ED... 13
3.3 Data collection ... 15
3.4 Data analysis ... 15
4. RESULTS ... 17
4.1 Introduction of the EPs ... 17
4.2 The formal role of the EP ... 19
4.3 The view of the EPs on their role... 20
4.4 The view of the medical specialist on the role of the EP ... 21
4.5 Collaboration ... 23
4.6 The effect of the EP on the patient flow ... 25
4.7 Reasons for difference in role expectations ... 27
5. DISCUSSION ... 29
6. CONCLUSION ... 30
6.1 Limitations and future research ... 32
REFERENCE LIST ... 34
APPENDIX A: Interview guide ... 38
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1. INTRODUCTION
In May 2016, the government, the municipalities, the healthcare institution and the health insurers in the Netherlands received a pressing letter from physicians and staff advisors from the Amsterdam Medisch Centrum (AMC). This letter sharply addressed the problem of overcrowding at the emergency department (ED). The patient inflow at the ED increased over the years, while EDs have limited capacity and thus, cannot cope with the increasing number of patients (Goslings, Gorzeman, Offeringa-Klooster & Berdowski, 2016). Overcrowding is already an observed phenomenon since 2012, but there is still no solution for this problem (Gaakeer, van der Erf, van der Linden & Baden, 2018).
A negative effect of overcrowding is ambulance diversions (van Steenbergen, 2017). When an ED is overcrowded, the inflow of new patients will be put on hold. In those cases, ambulances with patients that are going to such an ED, will be redirected to a nearby hospital that has enough capacity. Therefore, overcrowding at one ED triggers a domino effect, which implies that other neighbouring EDs will also be flooded. Subsequently, the transportation time for ambulances increases and the availability of ambulances thus decreases (Tuller, 2016).
One of the solutions to counter the problem of overcrowding, and thus ambulance diversion, is to improve the patient flow at the ED. Patient flow is defined as the speed at which patients are transferred from one step in the care process to the next (Drupsteen, van der Vaart & van Donk, 2013; deduced from Hopp & Spearman, 2001). In order to increase the quality and speed of acute care, a specialty is developed that is dedicated to the ED (Thijssen, Koetsenruijter, Giesen & Wensing, 2013). In 2008, this led to the creation of the profession of emergency physician (EP). The EP coordinates the work at the ED, monitors the patient flow and treats patients (Curriculum opleiding tot Spoedeisende Hulp Arts, 2014).
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influenced by collaboration between EPs and medical specialists. She describes factors that hinder collaboration, which in turn negatively affect the patient flow. She describes trust, clear formal agreements and commitment as factors that improve the collaboration between the EP and the medical specialist. However, according to Hall (2005), Sims, Hewitt & Harris (2015) and Suter, Arndt, Arthur, Parboosingh, Taylor & Deutschlander (2009) another important factor that improves collaboration is role clarity. Sims et al. (2015) define role clarity as the concept that employees have knowledge of each other’s roles and responsibilities. Earlier research from Johnson (2012) shows that a potential improvement in patient flow could be achieved by clarifying roles and responsibilities at the ED. However, she did not describe how those clear roles could improve the patient flow. Therefore, this paper will link the role clarity at the ED to collaboration. Furthermore, it is especially interesting to look at the EP’s role, since the EP is a relatively young profession in the Netherlands, and the role of the EP at the ED might not always be clear to everyone they collaborate with. Also, the role of the EP can differ per hospital in the Netherlands (Kathan, 2008). Therefore, the EP’s role in a hospital might be unclear for doctors who have worked in different hospitals throughout their career. Consequently, this paper will build further on the work of Reiring (2018), Johnson (2012) and Kathan (2008) by trying to explore the influence of role clarity on collaboration between EPs and medical specialists in the context of the ED in a Dutch hospital.
This paper will explore how the clarity of the EP’s role influences the collaboration between EPs and medical specialists at the ED, and in this way the patient flow. The research will be performed at the ED of a Dutch hospital. Hypothesized is, that role clarity has a positive influence on the collaboration and subsequently the patient flow. Therefore, the question that this paper will try to answer is: how does the clarity of the EP’s role affects the collaboration between EPs and medical specialists at the ED? Hence, this paper provides the reader with insight in the role that an EP can have at an ED and how this role is seen and appreciated by medical specialists. Next to that, the influence of the clarity of the EP’s role on the collaboration between EPs and medical specialists is described. The practical implications of this paper will leave managers with an idea of how EPs and medical specialists collaborate at an ED, and what possible improvements can be made with regard to the clarity of the EP’s role.
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2. THEORY
2.1 Patient flow
Patient flow is defined as the speed at which patients are transferred from one step in the care process to the next. This definition is retrieved from Drupsteen et al. (2013), who used the definition of flow from Hopp & Spearman (2001). This section will link overcrowding, which is discussed in the introduction, to the patient flow, and eventually to collaboration.
As already explained in the introduction, overcrowding is a hot topic. Overcrowding has a negative influence on patient flow, since it slows down the ED operations (Van der Linden, van der Linden, Richards, Derlet, Grootendorst & Van den Brand, 2016; Sun et al., 2013), and eventually leads to ambulance diversions (Van Steenbergen, 2017; Tuller, 2016). The reasons for overcrowding are both external as internal.
Derlet & Richards (2000) state that in the US, the inflow of patients increased over the years, while the capacity did not increase accordingly. Next to this, the complexity and acuity of the care increased. Furthermore, the arrival rate of the patient is a difficulty for the prediction of the inflow of patients, as the hospital has no influence on arrival patterns of patients (Green, Soares, Giglio & Green, 2005). When looking at the internal reasons for overcrowding, a lot of different factors come up that have an influence. The shortage of staff can be a problem (Derlet & Richards, 2000), but also waiting for a doctor or a medical specialist is identified as a factor that delays the patient flow (Miro, Sanchez, Espinosa, Coll-Vinent, Bragulat & Milla, 2003; Travers & Lee, 2006; Subash, Dunn, McNicholl & Marlow, 2004). Travers & Lee (2006) and Subash et al. (2004) state that because an EP is present at the ED, the waiting time for a doctor or medical specialists reduces, since the EP can perform this role. However, who can make which decisions about patients can differ per hospital (Nugus, Carroll, Hewett, Short, Forero & Braithwaite, 2010). In the Netherlands, EPs and medical specialists most of the time work together and consult each other in order to make a treatment plan and get patients through the ED (Reiring, 2018). Therefore, the medical specialists and the EPs need to collaborate, which improves the patient flow (Reiring, 2018). However, collaboration in a healthcare setting can be a challenge.
2.2 Collaboration
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order to provide care, the teams need to collaborate. The definition of collaboration used here is that of inter-functional collaboration, which is collaboration between two professional functions. Inter-functional collaboration is an unstructured, informal communicative process that is dependent upon peoples’ ability to trust each other, build meaningful relationships, and appreciate one another’s expertise (Ellinger et al., 2006, based on Mintzberg et al., 1996). Collaboration has been pointed out as a positive influencer of patient flow (Gittell et al., 2000; Powell & Davies, 2012). Nevertheless, collaboration between different specialties, which are professional functions, in a hospital is hard to obtain because of the high individualistic view of departments in a hospital, which is also referred to as silo mentality (Glouberman & Mintzberg, 2001). Thus, collaboration between specialties can be a challenge (Hewett, Watson, Gallois, Ward & Leggett, 2009). Lingard, Espin, Evans & Hawryluck (2004) and Hewett et al. (2009) talk about admission policy problems, where specialties are hesitant to admit a patient to their specialty ward. A second problem that they address is the issue of patient ownership, where one doctor is held responsible for a treatment that another doctor has performed. Next to this, intergroup forming, the forming of an ‘us and them’ culture in a hospital, is mentioned as an observed behaviour as well (Hewett et al., 2009). Those behaviours all seem to make it difficult for two or more specialties in a hospital to collaborate.
In order to overcome those problems, Reiring (2018) names commitment, trust and the existence and knowledge of formal and informal agreements as enablers of collaboration. However, the importance of role clarity is not addressed in her paper, while other authors name it as an important factor that can influence collaboration (Suter et al., 2009; Sims et al., 2015; and Hall, 2005). They state that role clarity positively influences the quality of the care by being a pillar for collaboration. Thus, the factor role clarity can be important when establishing collaboration. This is explained in the next section.
2.3 Role clarity
To follow Sims et al. (2015), role clarity is defined as the concept that employees have knowledge of each other’s roles and responsibilities. According to the findings of Suter et al. (2009) and Sims et al. (2015), employees in a healthcare environment benefit from knowing which tasks their job comprises and which tasks someone else’s job comprises.
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roles and responsibilities are. When the roles of employees who collaborate are clear to each other, they know what the other’s expertise and knowledge is. Also, each other’s strengths and weaknesses are known. Therefore, they value and respect each other and each other’s roles more (Henneman, Lee & Cohen, 1995; Nancarrow, 2004; Sims et al., 2015; Suter et al., 2009). Besides that, Schuler & Jackson (1985) state that due to unclear roles, conflicts between the collaborating entities may arise. In those cases, the collaborating entities have mismatched expectations about each other’s role. Because of this mismatch, employees who are in such a role will never live up to the expectations. This decreases the expertise and knowledge about someone’s role and therefore also harm their collaboration with others and eventually also the quality of care.
Thus, role clarity is seen as an important factor that positively influences collaboration, especially in emergency situations (Curnin et al., 2015). They investigate collaboration and role clarity in emergency situations. They state that in those situations, the need for role clarity is high. During emergency situations, the abilities and responsibilities of people who work together need to be understood in order to collaborate. However, the study mentioned is performed with a group of participants who work in emergency services (fire department, police department) and critical infrastructural services (energy transport, water transport). Since the ED is also an emergency service, it might be possible that the results are generalizable to the ED environment. This is in line with Johnson (2012), who states that a possible solution for improving the patient flow is clear roles and tasks for the staff who works at the ED. However, she does not elaborate on how role clarity exactly improves patient flow, but merely that it could be a possible solution.
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the EP and the medical specialist is investigated. This is shown in the conceptual model in figure 1.
Figure SEQ Figure \* ARABIC 1: Conceptual model
Role clarity
• Of the EP at the ED
Collaboration
• Between the EP and the
medical specialist
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3. METHODOLOGY
This study will analyse the link between the clarity of the role of the EPs and the collaboration between them and the medical specialists at the ED. To follow Edmondson & McManus (2007), this research has the characteristics of an explorative study. Explorative studies are used to answer how and why questions (Yin, 2003), in order to explore the relationship that exists between two constructs. This research will elaborate on earlier research of Reiring (2018), who already described the effect of collaboration of EPs and medical specialists on patient flow and came up with other constructs that influence the collaboration. This paper proposes that role clarity is another construct that has effect on collaboration. Since the collaboration and role clarity are not yet connected earlier in the context of an ED, this research is well suited for a case study. To gain deep knowledge on the phenomenon of collaboration between EPs and medical specialists and to understand the context in which it takes place, a case study was performed in which multiple specialists and EP’s were interviewed (Cavaye, 1996; Karlsson, 2016). Karlsson (2016) suggests that a single case study can be appropriate in order to obtain deep knowledge of a phenomenon. Further, because of the limited availability of time, a single case study is more suitable.
3.1 Case selection and case description
To investigate the effect of role clarity on collaboration, this study is performed at a large ED of a teaching hospital in the Netherlands. This hospital is especially fit for this research because it is one of the last hospitals in the Netherlands that started working with EPs at the ED. Therefore, the relationships between the different departments and doctors are still improving, which gives a clearer picture of how collaboration is built up. Also, this hospital is chosen as the case because of convenience, including location and access. Hence, data gathering can be facilitated in a short period of time (Etikan, Musa and Alkassim, 2016).
The subject of this paper is the collaboration between the EP and the medical specialist at the ED. This could be influenced by the role clarity of the EP. In order to understand the ED and the roles that the EPs and medical specialists have, they need to be explained.
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The residents diagnose and create treatment plans for the patients of their specialty and then discuss them with the assigned medical specialist. The medical specialist thus supervises his/her residents. Most of the time, this is done over the phone and thus supervision is at a distance. Medical specialists who are on call can come to the ED to supervise their residents and give them advice or to see patients themselves. If a medical specialist is needed at the ED, he/she must come to the ED. Nevertheless, no concrete agreements are made about how fast a medical specialist should be at the ED when called. Also, no agreements have been made about activities that medical specialists do next to their tasks at the ED. Thus, it is possible for medical specialists to perform other tasks when they are on call for the ED.
Specialty Residents at the ED/on call
Cardiology At the ED
Surgery At the ED
Internal medicine At the ED
Pulmonology At the ED
Neurology At the ED from noon
Urology On call
Paediatrics On call
Gastro-enterology On call
Gynaecology On call
Geriatrics On call
One of the tasks of the EP at the ED is the coordination of the department. The EP has an overview over the whole ED and identifies bottlenecks and addresses those. Also, the EP is present to recognize the critically ill patients, which is vital for the survival of those patients. EPs are especially trained for this, since recognition of life-threatening signs can be difficult (Ludikhuize, Smorenburg, de Rooij & de Jonge, 2012). Also, the EP can consult a medical specialist about an undifferentiated patient, where the problem of the patient is unclear and thus the specialty to which he/she needs to be assigned is unclear to. Next to those tasks, the EP can help the residents when they diagnose a patient and create a treatment plan for them. Finally, the EP can perform patient care, which means that the EP diagnoses a patient and creates a treatment plan. The diagnosis and treatment plan that is created should be discussed with the medical specialist who is on call for the assigned specialty. Also, discharging a patient, needs to be discussed with the medical specialist on call.
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Therefore, the situation on the ED is as described in table 2. In this table, the collaboration between the different parties is displayed.
Relationship between the different professions at the ED
EP Medical specialist Resident
EP - - Must discuss about patients and treatment plan. - Can consult the medical specialists about an undifferentiated patient. Mostly via telephone. - Same hierarchical level.
- Can advise the residents about the patients and treatment plans they make. - Can help the resident during an assessment. - Higher hierarchical level.
Medical specialist - Can be consulted by the EP about an
undifferentiated patient. - Can be consulted by the resident/EP about a patient or a treatment plan. - Same hierarchical level.
- - Supervises the resident, mostly on a distance. - Assesses the residents’ performance.
- Higher hierarchical level.
Resident - Can ask the EP questions
about patients and treatment plans.
- Can get help during the assessment of a patient from the EP.
- Lower hierarchical level.
- Gets supervision from the medical specialist, mostly via the telephone. - Must discuss the patients they assess with the medical specialist.
- Lower hierarchical level.
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The EP works together with the medical specialist on call, by discussing the treatment plan and diagnosis of a patient. The EP also discusses the admission of a patient to the specialty ward or discharge of a patient with the medical specialist on-call. Next to this, the EP can supervise the residents of the specialisms during intakes/assessments and can answer questions and give them advice. The medical specialist is on call for the EPs as stated earlier, and for the residents to discuss patients. Furthermore, the medical specialists on call supervise and assess the residents of their specialty.
3.2 The process of the ED
In this case, the process for patients at the ED is as follows: a patient can be brought in by ambulance, can be referred via a GP to the medical specialist, or can go to the ED via
self-Figure SEQ self-Figure \* ARABIC 2: Relationships between actors at the ED.
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referral. The patient will be assigned to the specialty when he/she has been registered at the ED. This happens when the ED is called by the ambulance or the medical specialist, who receives the call from the GP, or when the patient is at the desk of the ED. It is possible for the EP to subscribe the patient to another specialty if this specialty is more suitable for the injury/disease. Changing the specialty can be done with consultation of the medical specialist for the five key specialisms (cardiology, surgery, internal medicine, neurology and pulmonology). If the patient needs to be assigned to another specialty that is not one of the key specialisms, the EP/resident needs to discuss this with the medical specialist of that specialty.
Patients who are brought in by the ambulance and are critically ill, are treated immediately. When the EP suspects that a patient could be critically ill after the registration, the EP can take a quick look. If the patient is indeed critically ill, he/she will immediately go to a treatment room. When the patient is referenced by a GP or if the patient came to the ED by him/herself, he/she needs to wait in the waiting room. He/she will be triaged within ten to fifteen minutes. Triaging is done by a dedicated triage nurse who is trained for the triage process. During the triage process, the severity of the injury is determined and some diagnostic tests are requested (for example blood tests). Then, the patient must wait before he/she can be treated. The period of time that the patient must wait depends on the severity of the injury. Patients that have minor injuries, and thus low severity, can be treated via the fast-track.
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The data presented here was retrieved from a single case study at the ED of a large teaching hospital in the Netherlands. The logic of Eisenhardt (1989), who states that the ideal amount of cases in a case study is between four and ten, was used to determine the number of interviews that are conducted. To come to a reasonable amount of data and reach saturation, twelve interviews are conducted. Interviews with five EPs and six specialists are conducted in order to observe the relationship between the clarity of the role and their collaboration. Both EPs and medical specialists are interviewed to reduce the risk of biased data. Next to that, one interview with a manager is conducted in order to get a different perspective on the examined situation. The residents are also present at the ED but are not interviewed. The reason is that this paper focusses on the collaboration between medical specialists and EPs, and thus the residents are beyond the scope of this research.
The interviews were semi-structured and had a duration of 30 minutes on average. The interviews are conducted by one researcher. When details were missed, the interviewees were contacted again, and follow-up questions were asked. The interviews were held in an environment that is familiar to the interviewee and were recorded, if approved, in order to preserve the quality and richness of the data. The interviews are based on an interview guide, which can be found in appendix A, in order to make the data comparable and analysable. However, if some subjects seem more important during the interview, more questions were asked about that subject. Besides the interviews, there were two observations on the ED floor by a researcher who observed the processes that are in place. This field research was conducted by one researcher who took notes and asked questions about the processes that are present at the ED. The notes are used complementary to the interviews held. Thirdly, internal documents of the organisation about the formal role of the EP and about the formal agreements between EPs and medical specialists are used in order to retrieve information that is relevant. Hence, multiple data gathering methods are performed.
3.4 Data analysis
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subjects in the interviews, then the quotes were labelled with a first order code which explains more precisely what the code is about. This practise is shown in figure 2, which displays a coding tree. The whole coding tree can be found in the appendix B. After the coding process, patterns were identified in the codes, which means that the links between the codes where examined. In order to find patterns in the data, first all the EP data was grouped and analysed. Then, the data from the medical specialists was grouped and analysed. After that, the links between the codes of both the EPs and the medical specialists were compared in order to see how they differ. Thus, first patterns are found in the EP data and the medical specialist data, and next, the patterns that were found were compared to each other. Those patterns and the important differences in those patterns are in the results section.
Coding Tree
Quotes First order code Theme
"You can tell that some (medical specialists) really like it and they will be here quite a lot, they have a chat with you: “hey how is it going? What can we do?” and some that just will never show their face and you can only reach them by phone. Some I haven’t seen over a year."
Commitment
Collaboration "Obviously, we all want the best patient care so we have that
goal in common." Common goals
"It is because we got the general overview of the whole department. And they are just looking at their patients. So it could be that my department is exploding, lots of patients everywhere, but the internal medicine guy only got 2 patients. So he is like, I’ve got 2 patients, what are you harassing me for, I got 2 patients only. But to me, they can be really in my way."
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4. RESULTS
In this section, the results of the research are explained. First, in order to better understand the discussion about the tasks of the EP, the reasons for hiring EPs are described. This includes the concerns that medical specialists had about the introduction of the EPs and shows how the hospital decided which role the EP should get when introduced. Secondly, the formal description of the role of the EP in the hospital is given in order to understand how clear the role of the EP is. Thirdly, the role of the EP as seen by the EP him/herself is given, in order to show which tasks the EPs perform and find important. Fourthly, the role of the EP is described from the perspective of the medical specialists. Fifthly, the effect of the differences in role expectations on collaboration is addressed, together with the effect of the role of the EP on patient flow. Lastly, the reasons for the difference in expectations are presented.
4.1 Introduction of the EPs
When conducting the interviews, it became clear that the introduction of the EP was a long-debated subject at the hospital. As one of the EPs mentioned, there were two groups of medical specialists, namely the ‘believers’ and ‘non-believers’ of introducing the EP. There are a few reasons why those two groups existed.
Some medical specialists worried that the introduction of EPs would interfere with the education that the residents got at the ED. They felt that when another doctor will work at the ED, he/she will take over the work of the residents and they will not learn anything anymore.
MS03: “There are also concerns about the education of the residents. From an educational point of view, the resident needs to experience emergency situations. If
the EP overtakes those situations, the resident sees fewer emergency situations.”
Those concerns were especially present at the specialisms that had a large residents pool. Specialisms that do not have residents at the ED were much happier, since they had to do all the work at the ED themselves. As one of the neurologists indicated, the EP could help them with their patient load and thus decrease the pressure on their shoulders.
MS04: “We did not have residents, so we would have to go to the ED constantly. For us, things could only get better, so we were not against the introduction of the EP. We hoped that we would benefit from the EPs and that the amount of work for us at the ED would decrease. So, we neurologists were not sceptical against the
introduction of the EP.
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that EPs might overtake tasks and jobs that the medical specialists did. Thus, a clear role description was lacking.
Also, some specialists just did not think that the EPs were needed at the ED. Their opinion was that in the time that they were a resident, they could also manage to do their work at the ED without EPs, so why should they be needed now.
On the other hand, there were also reasons in favour of hiring EPs. Firstly, because the hospital is a teaching hospital, young and unexperienced doctors (residents) work at the ED under supervision of a medical specialist. However, the medical specialist gives the supervision from a distance, since they also have other tasks in the hospital. Therefore, the residents were on their own at the ED most of the time. Subsequently, a situation existed in which the most unexperienced doctors saw the patients that might were the most ill.
EP03: “The goal of our job is to improve the quality of care at the ED. Before we were introduced, young unexperienced doctors ran the ED, with supervision from medical specialists who were not on the site. We think that supervision by someone
that is present at the ED is much better, and the hospital thinks that too. That is why we were hired.”
According to a medical specialist, the hospital at one point also indicated that they could not justify anymore that they did not have EPs at the ED. Primarily because of the unexperienced doctors at the ED.
MS03: “At one point, the hospital stated they could not justify it anymore that they had an ED without EPs. Where residents, experienced and unexperienced, are
present at the ED.”
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Manager: “The EPs are introduced for multiple reasons. One of those reasons is the coordination of the ED. At a certain moment, every doctor sees their own emergency patients, and no one has the oversight of the department. Normally, the
coordinating nurse has the oversight of the logistics, however, we did not have someone who had the total medical oversight. That is why we introduced EPs.”
This coordinating role is also more needed because of the large increase in the number of patients.
Manager: “In ten years, we grew from 15.000 patients to 32.000 patients, so we have 100% more production. That thus implies that the pressure on doctors has increased enormously, which justifies the presence of someone who coordinates
and keeps the oversight.”
From those statements, the conclusion can be drawn that some recognized the need for EPs at the hospital and that there were medical specialists at the hospital who were in favour, the ‘believers’. However, there was also a lot of resistance towards the introduction of the medical specialists at the hospital, the ‘non-believers’. Thus, when the EPs were introduced in the hospital, it took a while for the EPs and the medical specialists to get used to each other and find out how they can work together. The EPs indicate that this improved enormously, and trust grew over time. Nevertheless, there are still doctors at the hospital that do not want EPs or do not know what the EPs exactly do. The following sections build further on this and will explain the role of the EP formally, as regarded by the EPs and as regarded by the medical specialists.
4.2 The formal role of the EP
The formal role of the EP is described according to a few internal documents that the organisation has shared. From those documents, the following tasks for the EP are stated. According to the agreements, all tasks are evenly important. However, with neurology and urology, the agreement is made that the coordinating task and the care for the critically ill patients are more important than the other two tasks.
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The second task of the EP is to see critically ill patients. Critically ill patients are patients who are brought in with an injury that needs treatment right away. Patients with vague complaints and who are therefore not yet assigned to the right specialism, are also classified as critically ill patients. In order to spot a critically ill patient, the doctor who assesses a patient needs to see right away if the patient is critically ill or not. This is called the ‘clinical look’ by the doctors, which is possessed by doctors with a lot of experience in assessing patients. The patients at the ED are seen by residents who are in training and do not necessarily have this ‘clinical look’, according to the doctors. They state that only very experienced residents can quickly spot a critically ill patient. Therefore, the EP can check quickly if the patients that are assessed by unexperienced doctors are not critically ill. So, the EP is present to guarantee the safety of the patient, but also that of the unexperienced resident.
Next to those two tasks, the EP can help mainly unexperienced residents when they see patients and help the residents when they have questions or when they make a treatment plan. Lastly, the EP can assess patients in order to reduce the number of patients in the waiting room. The EP then first assesses the patient, creates a treatment plan and then discusses this treatment plan with the medical specialist of the specialism where the patient has been registered to. This will reduce the patient load for the residents because the EP also assesses patients, instead of only the residents.
4.3 The view of the EPs on their role
According to the EPs, their main tasks are coordinating the department and assessing the critically ill patients. The EPs stress, that the coordinating role is of great value. The coordination of the department is important to keep an overview of the department and to keep activities going, especially during the very busy times. According to them, the coordinating task is important in order to keep the patient flow up to speed and to protect the safety of all the patients at the ED.
EP03: “We need to pay attention constantly. Like when you requested an echo and it takes already half an hour, and you call the department and they did not even transport the patient to the department yet. Or they did not had time yet. So, there
are a lot of actions that follow up on each other, and we have to monitor this flow.”
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department. I think that a signalling, pushing and coordinating job is important at those times.
When it is busy, the EP needs to coordinate the ED and help with the care for the critically ill patients, which consumes all their time. Therefore, there is no time to do other tasks when there is only one EP per shift, which is the case on most days. There are two EPs during the day shifts on Monday and Friday, because those are the busiest days. When there are two EPs, one can coordinate, and the other EP can assess patients. Subsequently, the EPs state that there is no time to see patients or to help the residents with their patient load when there is only one EP at the ED. Consequently, when the ED is busy, the patient load of the residents also increases.
EP04: “If there is only one EP, he/she will not be able to also see patients in a shift. Then, the coordinating job and the critically ill patients takes up all your time. We have made agreements that that are our core tasks. I like to help the residents and to see patients, but if I would do that, I would not be able to keep an
overview of the department. That is not what we want.”
EP04: “We have the coordinating task over the department together with the coordinating nurse. Next to that, we make sure that our department is safe for the
patients and for the residents and nurses.”
4.4 The view of the medical specialist on the role of the EP
The medical specialists appreciate the role of the EP when he/she sees the critically ill patients. They see the EP as an improvement to the ED since they help the residents with the care for the critically ill patients. Moreover, most of them think that it helps when there is someone with experience and knowledge at the ED.
MS01: “You notice that the EPs have had a three-year training program to identify the critically ill patients. They are way better in that than the average unexperienced resident. They also know what to do and have the skills to stabilize
a patient. That is something I appreciate.”
MS04: “Before the EP, the critically ill patients were the responsibility of the nurses of the ED. But the care for the critically ill patient cannot be done by a nurse, I think it is more professional if a doctor should do that. For example, the decision to call the anaesthetist and to intubate a patient. You cannot let the nurses
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Next to that, the medical specialist especially finds the EP a good addition, since they can help their residents with the patient load. When their residents at the ED are busy, the EP can see some patients for them.
MS04: “When there are multiple patients with neurological problems at the ED, we can arrange with the EP that they can see a patient. Hence, the neurologist or the residents of neurology have time to see the other patients. So, in that way, I like
our collaboration. The patient care is then facilitated by the EP, where earlier, the neurologist or the resident would have seen the patient. So, I think that adds
value.”
According to the EPs, the specialists appreciate it if the EP sees patients for their specialty when the resident of that specialty is busy. Then, the patient load decreases and the pressure on the shoulders of the resident is also less.
Therefore, some of the medical specialists prefer that, if the EP would see more patients to improve the flow, instead of coordinating the department. Hence, they should not do their prioritized task, namely coordinating. According to the EP, friction occurs because of those situations. This friction is also acknowledged by some medical specialists.
MS05: “The EP, to my knowledge, coordinates the ED. So, on the one hand they coordinate the ED and on the other hand they help my residents when they are very busy. They do not do help that often and I think that they should do that more.
I don’t know what their schedules are during a day, but sometimes I would like that the EP helps my residents more often.”
This coordinating task, which is also called managing, returns in another interview, in which a medical specialist indicates that this should not be the way the EP improves the patient flow. In line with the former quote, those medical specialists think that the focus should be more on seeing patients in order to decrease the number of patients that wait for treatment. They state that the EPs are doctors and not managers.
MS06: “There are a lot of people who coordinate and manage and have those kinds of jobs, but at the ED, people need to be assessed. Of course, it is important
if someone keeps an oversight over the department, but I think that the doctors should be the ones who need to see patients. They should not be managers, they
23 MS05: “I think that coordinating could also be done by a manager instead of a doctor. Because the
EP is also a doctor and I think that if you are a doctor you should also assess patients.”
Consequently, most medical specialists do appreciate the coordinating role at the ED, but some do not think that this should be the core task of the EP. Especially not during the times that there are a lot of patients and when it is very busy, where EPs think that coordination is especially useful during busy times. So, the importance of the coordinating role for the EP seems unclear to them and seems to be less appreciated. This sometimes results in friction and incomprehension between the EPs and medical specialists. Almost every day, the ED of the hospital is very busy and therefore this situation can occur a lot.
EP02: “There are doctors who think that we should only see patients, however, we think that coordination is very important. We have to worry about patient flow, we have to check on the patients who are at the ED and be available to supervise if new patients come in. I think that the most resistance is towards that. That we do that for most of the time. Because most of the day we are just coordinating. If it is really busy and there are a lot of patients, a lot of specialists think: “Yeah but why
doesn’t the EP just see three patients for you?”. Well, because we are busy with the getting all the other patients out the ED. There is the most friction. “
4.5 Collaboration
All the EPs indicate that the collaboration between them and most of the medical specialists is fine, however, some individuals are harder to collaborate with.
EP02: “I can work with all the specialisms, there are only some specialists that I cannot collaborate that well with.”
According to the EPs, those medical specialists do not see the need for the EPs at the ED and do not value their expertise. The EPs state that some medical specialists do not know what the added value of the EP at the ED is, and that their work is sometimes invisible for the medical specialists since they are not on the ED.
EP03: “We do a lot for that department, but there exists a lot of ignorance about what we do for them. For them, a lot of our work is invisible or unclear. “
Some EPs state that the invisibility of their work and the lack of awareness about their job makes collaboration difficult because they do not feel valued in this collaboration. They feel like they do not get the appreciation for the work that they do and the knowledge and expertise that they have, because this is not seen by the medical specialists, since they are not at the ED.
24 surgeon who also said that the scan was necessary. So, I called back, and requested the scan, but the
radiologist said that I should have called a trauma-surgeon in order to get the request approved. It took hours before the patient could get the scan.”
The EPs state that those situations occur less now than in the past, but that they still occur sometimes.
The EPs also state that only one EP per shift is not enough to do all the tasks that are desired of the EP. As explained earlier, this led to the choice of the EPs to have two prioritized tasks, namely assessing critically ill patients and coordination of the ED. If residents cannot cope with the number of patients, the EPs would like to help, but this is not always possible because they have other tasks. This sometimes hurts the collaboration since it is confusing for medical specialists to know what they can expect from the EPs. Some of the medical specialists indicate that they do not know when it is busy for the EP at the ED and when it is not, so they do not know when the EP will be able to help with the patient load. Some medical specialists indicate that unclear expectations therefore make collaboration difficult, since they cannot trust the EP to perform patient care if they are also coordinating.
MS05: “No, it is not completely clear what the EP’s job consists of. I see that some EPs are busy with assessing patients and helping to get as many patients through the ED as possible. And with other EPs, I strongly get the feeling that they are managing, but I can be wrong of course. I don’t know what
the purpose is actually, but that is what I see.”
Another issue that came up and affects the collaboration between the medical specialists and the EPs according to some medical specialists, is the preference of the EP. As mentioned by a few medical specialists and EPs, every EP has different preferences for specialisms. Some have more affection with the surgical specialisms while others prefer the diagnostical specialisms. This also depends on the abilities of the EP with regard to the different specialisms. According to some of the medical specialists, the preference of the EP for a certain specialism influences the number of patients that they assess for a certain specialism. The medical specialists state that they understand that this is present, but they cannot trust that every EP will help with every specialism equally.
MS06: “It also depends on what the EP likes. One like surgery better and it shows. The other likes to puzzle, more like internal medicine, so there is also a difference between EPs. I think that that is also a
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As mentioned in one of the quotes above, the role of the EP is not always clear to medical specialists and leads to frustration and incomprehension by EPs and medical specialists. Since the EPs indicate that there are still medical specialists who do not value them for what they do and that some medical specialists do not understand what their main tasks involve. On the other hand, some medical specialists indicate that the EPs could be more useful in another role at the hospital and some medical specialists indicate that they do not know what the EP’s most important tasks are. This results in mismatched expectations about the role of the EP, which have a negative influence on the collaboration between them and some medical specialists. This becomes also evident from the next quote, wherein a medical specialist expects that an EP can assess a patient for them while the EP might have other tasks that he/she has to do at that moment.
EP02: “They do not have assistants here, and in the evening, they are not in office but at home. And sometimes, if they are called, they then call us and say: “There is a patient on its way to the ED, he has a kidney stone and the GP is not able to get him/her pain free. So, you just have to do this, and you
just have to do this, and it is not a lot of work so you can do that for me.” Then, I think: “I did not even hear a question”. In my opinion, they can ask us if we want to do that for them and if we have
time for it, instead of ordering us what to do.”
This has a negative influence on the collaboration with some of the medical specialists, because the expectations of both groups about the EP’s role do not match. As many EPs and medical specialists have already indicated: “You like what you know”, and since some of the medical specialists do not know who the EPs are and what they do, they also do not like it. The EPs do not always feel valued and appreciated in their work and expertise, where medical specialists cannot always trust on the EP to perform patient care, instead of coordinating the department. Both appreciation and trust are essential parts of collaboration as mentioned by Ellinger et al. (2006), which is based on Mintzberg et al. (1996). Although the EPs and medical specialists state that their collaboration has improved over the years, there are still problems like those explained above.
4.6 The perceived effect of the EP on the patient flow
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at the same time. Next to that, the EP comes across bottlenecks which he/she can discuss with the medical coordinator. The medical coordinator can then discuss those bottlenecks and make other people in the hospital aware of them. Thus, by being present at the ED, the EPs can spot bottlenecks which can be resolved by new policies.
EP02: “I think that our influence on the patient flow is limited because of other factors like waiting for test results, waiting for supervision or waiting for beds. We
have more indirect influence on those factors, because since we are here, there is more attention for those problems. So, on the scale of one working day, our influence is especially on the safety of the patient and a little bit on the patient flow, because you see where the bottlenecks are and can solve those. And on a
bigger scale, we have influence on the organisational structure.”
Next to a direct influence on the patient flow, the EP also has an indirect effect on the patient flow. This indirect effect is established via the improvement in safety for the patients that has been reached because of the presence of the EP at the ED. Since the EPs are more experienced in the assessment and the treatment of patients than the residents, they state that there are also fewer medical errors made at the ED. Those medical errors increase the treatment time of a patient, since they need more treatment to correct the errors. According to the EPs, those errors are made less often because the EP is present at the ED, and therefore, the treatment time of patients has also decreased.
Most of the medical specialists however do not see the improvement in the patient flow, due to the coordinating role. The results of the coordinating role at the ED are not visible for them, so they do not find the coordination as important as other tasks of the EP. They state that the EPs especially improve the patient flow if they see the patients for their residents. Subsequently, all the medical specialists mention that it is hard to measure the impact of the EP, since the introduction of the EP happened simultaneously with an enormous increase in patients. Therefore, the effect of the EP on the patient flow is difficult to identify.
27 4.7 Reasons for difference in role expectations
As can be read above, there are clearly different expectations about the role of the EP, and there are a few reasons for this. Firstly, the medical specialists especially value the EP when he/she does patient care, which consists of assessing critically ill patients, assessing patients for their specialism when their residents are busy and helping their residents with questions regarding patient care. Hence, work they can see the results of and where they benefit from. The coordinating role is not always appreciated by medical specialists, since they are not present at the ED to see what the EP does, and they are also not involved in the coordinating process. Therefore, the results of the coordinating task of the EP are not clear to them.
EP03: “What makes it hard for us, is that our contribution to the care pathway of a patient is not visible to the medical specialist. For the resident, it is very helpful what we do, but for the medical specialist it is sometimes invisible. They only know about the patients that we saw for their residents, and they think: “Oh that is what you did”. But they do not see that we deliver care to all the other patients as well.”
According to the EPs, the coordination is important because there are many different specialties at the ED. Every doctor can keep the oversight for their own department. But at the ED, patients of all the departments are in one department, which is the overview that they need to coordinate. Especially when it is busy, the EPs stat that there must be someone who keeps the overview of all the patient streams at the ED.
EP02: “If you are busy with something, and you are focussed on that, it is really difficult to see everything that happens around you. That is exactly why we are coordinating, so that
there is someone who has the overview. So, you can’t expect from others that they do the same. But it can lead, and I understand that, to irritation. They then think:” I am working
really hard here, and she is just sitting there, go do something.”.
EP01: “It is because we got the general overview of the whole department. And they are just looking at their patients. So, it could be that my department is exploding, lots of patients everywhere, but the internal medicine guy only got two patients. So, he is like: “I’ve got two
patients, what are you harassing me for.” But to me, they can be really in my way.”
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Next to that, the prioritization of the coordinating role is not known by the specialists. The formal agreements about the collaboration between the EPs and the medical specialists are mainly about when the EP can see patients for the medical specialists, and when the EP can help residents. It is not clearly stated that the coordinating task is prioritized above treating patients and helping residents. This prioritization is only formally stated in the agreements with two of all the eighteen specialisms with which the EPs have agreements. Thus, a lot of medical specialists are not formally informed about this regulation.
Thirdly, most medical specialists indicated that there were no formal agreements made between the EPs and their specialism. They indicated that the working conditions between them and the EPs occurred naturally over time by working alongside each other. One medical specialist did mention the agreements but was not aware of the importance of the coordinating task. Hence, the agreements wherein the prioritization of the coordinating role is explained, might not be known by all the medical specialists of that specialism.
MS04: “Well, we do not have formal agreements, as on paper, it just more or less emerged.”
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5. DISCUSSION
From the results section, it becomes evident that different expectations exist of what the EP should do and what the EP’s most important tasks are. In situations where the two groups have different expectations about each other’s tasks, frustration and tension may occur. This may sometimes has a negative effect on collaboration between the EPs and some medical specialists. The difference in expectations about the role can be caused by some reasons.
Firstly, this difference in expectations can be explained by an unclear role resulting from unclear formal agreements. In these situations, it could be the case that some medical specialists do not have the information about the EP’s exact role and are not aware of the priority they have for the coordinating role, instead of assessing patients. This is due to the agreements wherein no specific information is given about this prioritization to most of the specialties. Hence, some medical specialists do not know that the coordinating role is more important than other roles. Also, some medical specialists are not aware of the fact that there are agreements about the collaboration with the EPs and thus do not have the right expectations of the EP. Making agreements in contracts between two parties can be an effective way to define roles
and understand the boundaries of those roles (Carson, Madhok & Wu, 2006). Consequently,
agreements about the roles can be a guideline for collaboration between two parties. They describe and regulate how the two parties collaborate, in order to minimalize conflict and tensions and thus improve collaboration (Carson et al., 2006). Nevertheless, the prioritizing of the coordinating role has not been included in most of the agreements with the medical specialties. Thus, the description of the role of the EP is incompletely captured by the formal agreements between the EPs and the medical specialists. Therefore, the agreements do not clarify the EP’s role and hence, do not improve the collaboration between the EPs and the medical specialists. The unclear roles could thus be a reason for less appreciation for the EP’s role and the tasks that the EP performs, and, the expertise that the EPs have in those roles. According to Ellinger et al. (2006), based on Mintzberg et al. (1996), the appreciation of each other’s expertise is an important part of collaboration, and therefore, the collaboration is sometimes hindered by those unclear roles.
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EP, so which specialism/specialisms an EP likes more, influences the amount of help that an EP gives to a certain specialism. Therefore, personal differences between the EPs exist and medical specialists cannot always trust the EP in how much help they receive for their patients, since there are also no agreements about. Thus, the medical specialists state that they cannot always trust the EP in the way that the EP exactly does what the medical specialists expect. This trust is also an important part of the collaboration (Ellinger et al., 2006, based on Mintzberg et al., 1996). Hence, the unclear agreements about the role of the EP could result in less trust from the medical specialists towards the EPs. This decrease in trust can have a negative influence on the collaboration between the EP and the medical specialists.
Secondly, the value that both parties have for the coordinating role of the EP at the ED does not seem equal. It could be the case that the medical specialists do not agree with the EPs on the importance of the coordinating task for the EPs. Consequently, the expectations that the medical specialists and the EPs have about the role of the EP differ, because both have a different opinion on what the EP should do. As mentioned before, some medical specialists state that the EP would have more value if they would see patients at the ED, instead of coordinating the department. They state that assessing patients improves the patient flow more than coordination. The EPs on the other hand say that the coordinating role is very important for the patient flow at the ED and find this their core task. Subsequently, it could be the case that the role of the EP is clear to the medical specialists, but that they do not agree on this role. Then, the problem is not that the role of the EP is not valued because of unclear roles, but because there is a disagreement about what the role of the EP should be. Because the medical specialists and EPs both have a different opinion on which tasks are the most important at the ED. It could thus also be the case that those different opinions can sometimes lead to frustration and incomprehension about the role of the EP, instead of the unclarity of the role, which then negatively influence collaboration.
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6. CONCLUSION
From this research it becomes clear that there exists a mismatch in what the most important tasks of the EP should be at the ED. Where some medical specialists stress the importance of the assessment of patients, the EPs mention the importance of coordination of the department. This mismatch can sometimes have a negative effect on collaboration between medical specialists and EPs. This paper cannot give any recommendations about which tasks should be the most important in the role of the EP. However, it can conclude that there are different opinions on which tasks should be the most important for the EP. EPs and some of the medical specialists both have different suppositions about what the main tasks of the EPs should be. This could be due to no clear formal agreements about the role of the EP, which lead to different expectations. It could also be the case that is somewhat clear, but both parties just have different opinions on the most important tasks of the EP and therefore disagree.
Altogether, it is hard to distinguish between unclear agreements and different opinions in this case, since both are present. A plausible conclusion is that both unclear agreements and opposing opinions create a situation wherein expectations about the role of the EP differ. Therefore, there can be concluded that the role of the EP in Dutch hospitals is still not always clear, since there is a lot of discussion about which tasks he/she should perform which results in a mismatch in expectations. This also holds for the collaboration between EPs and medical specialists, which can be negatively influenced by this mismatch in expectations that exists about the role of the EP. This research adds to the literature of role clarity of the EP at the ED in the Netherlands. This paper helps to identify which problems about the role of the EP exist and how clear the role of the EP actually is.
6.1 Limitations and future research
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performed in other hospitals to investigate whether the findings of this paper are also applicable to those.
Besides that, all the medical specialists mention that at the same time the EP was introduced, the number of patients at their ED increased enormously. Therefore, the influence of the EP on the patient flow is hard to measure, since their impact is diluted by the increase in patients. Next to that, some of the interviews were conducted before the theory part was finalized. Therefore, the direction for the questions was hard to determine and made the questions more general. This resulted in more general answers too. The actual link between the role clarity of the EP and the collaboration between the EP and the medical specialists is only addressed in a few interviews. In other interviews, those two constructs are mentioned but are not linked to each other. Due to time constraint, there was no chance for a second round of interviews which could have added more relevant data to the subject. Hence, in order to understand the findings of this paper better, more research could be done with more specific questions to the subject, especially about the direct link of role clarity to the collaboration.
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REFERENCE LIST
Carson, S. J., Madhok, A., & Wu, T. 2006. Uncertainty, opportunism, and governance: The effects of volatility and ambiguity on formal and relational contracting. Academy of
Management Journal, 49(5): 1058-1077.
Cavaye, A. L. 1996. Case study research: a multi‐faceted research approach for IS. Information Systems Journal, 6(3): 227-242.
Curnin, S., Owen, C., Paton, D., Trist, C., & Parsons, D. 2015. Role clarity, swift trust and multi‐agency coordination. Journal of Contingencies and Crisis Management, 23(1): 29-35. Derlet, R. W., & Richards, J. R. 2000. Overcrowding in the nation’s emergency departments: complex causes and disturbing effects. Annals of Emergency Medicine, 35(1): 63-68.
Drupsteen, J., van der Vaart, T., & Pieter van Donk, D. 2013. Integrative practices in hospitals and their impact on patient flow. International Journal of Operations & Production
Management, 33(7): 912-933.
Edmondson, A. C., & McManus, S. E. (2007). Methodological fit in management field research. Academy of Management Review, 32(4): 1246-1264.
Eisenhardt, K. M. 1989. Building theories from case study research. Academy of
Management Review, 14(4): 532-550.
Ellinger, A. E., Keller, S. B., & Hansen, J. D. 2006. Bridging the divide between logistics and marketing: facilitating collaborative behavior. Journal of Business Logistics, 27(2): 1-27. Etikan, I., Musa, S. A., & Alkassim, R. S. 2016. Comparison of convenience sampling and purposive sampling. American Journal of Theoretical and Applied Statistics, 5(1): 1-4. Gaakeer, M., van der Erf, S., van der Linden, C. & Baden, D. 2018. Drukte op de SEH vergt integrale aanpak. Retrieved from
https://www.medischcontact.nl/nieuws/laatste-nieuws/artikel/drukte-op-de-seh-vergt-integrale-aanpak.htm at 13 September 2018.
35
Glouberman, S., & Mintzberg, H. 2001. Managing the care of health and the cure of disease— Part II: Integration. Health Care Management Review, 26(1): 70-84.
Goslings, C., Gorzeman, M., Offeringa-Klooster, M. & Berdowski, J. 2016. Brandbrief ’Regionale spoedzorg - de rek is eruit’ [Open letter]. Retrieved from
https://www.spoedzorgnet.nl/sites/default/files/documents/brandbrief_regionale_spoedzorg_-_de_rek_is_er_uit_2016-05-19.pdf at 13 September 2018.
Green, L. V., Soares, J., Giglio, J. F., & Green, R. A. 2006. Using queueing theory to increase the effectiveness of emergency department provider staffing. Academic Emergency
Medicine, 13(1): 61-68.
Hall, P. 2005. Interprofessional teamwork: Professional cultures as barriers. Journal of
Interprofessional Care, 19(sup1): 188-196.
Henneman, E. A., Lee, J. L., & Cohen, J. I. 1995. Collaboration: a concept analysis. Journal
of Advanced Nursing, 21(1): 103-109.
Hewett, D. G., Watson, B. M., Gallois, C., Ward, M., & Leggett, B. A. 2009. Intergroup communication between hospital doctors: implications for quality of patient care. Social
Science & Medicine, 69(12): 1732-1740.
Hopp, W.J. & Spearman, M.L. 2001. Factory Physics. New York: Waveland Press.
Jackson, S. E., & Schuler, R. S. 1985. A meta-analysis and conceptual critique of research on role ambiguity and role conflict in work settings. Organizational Behavior and Human
Decision Processes, 36(1): 16-78.
Johnson, M. 2012. Improving patient flow through the emergency department. Journal of
Healthcare Management, 57(4): 236-243.
Karlsson, C. 2016. Research Methods for Operations Management (2nd Edition). New York:
Routledge.
Kathan, C. D. 2008. Emergency physicians in the Netherlands: The development and
organizational impact of new multidisciplinary professionals in Hospitals. Thesis,
University of Groningen, Groningen, The Netherlands.
36
Lingard, L., Espin, S., Evans, C., & Hawryluck, L. 2004. The rules of the game:
interprofessional collaboration on the intensive care unit team. Critical Care, 8(6): 403–408. Ludikhuize, J., Smorenburg, S. M., de Rooij, S. E., & de Jonge, E. 2012. Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. Journal of Critical Care, 27(4): 424-e7. Mattessich, P. W., & Monsey, B. R. 1992. Collaboration: What Makes It Work. St. Paul: Amherst H. Wilder Foundation.
Mintzberg, H., Jorgensen, J., Dougherty, D., & Westley, F. 1996. Some surprising things about collaboration - knowing how people connect makes it work better. Organizational
Dynamics, 25(1): 60-72.
Miro, O., Sanchez, M., Espinosa, G., Coll-Vinent, B., Bragulat, E., & Milla, J. 2003. Analysis of patient flow in the emergency department and the effect of an extensive reorganisation.
Emergency Medicine Journal, 20(2): 143-148.
Nancarrow, S. 2004. Dynamic role boundaries in intermediate care services. Journal of
Interprofessional Care, 18(2): 141–151.
Nederlandse Vereniging van Spoedeisende hulp artsen. 2014. Curriculum opleiding tot
Spoedeisende Hulp Arts. Curriculum of Nederlandse Vereniging van Spoedeisende Hulp
Artsen, Utrecht.
Nugus, P., Carroll, K., Hewett, D. G., Short, A., Forero, R., & Braithwaite, J. 2010. Integrated care in the emergency department: a complex adaptive systems perspective. Social Science &
Medicine, 71(11): 1997-2004.
Powell, A. E., & Davies, H. T. 2012. The struggle to improve patient care in the face of professional boundaries. Social Science & Medicine, 75(5): 807-814.
Reiring, S. 2018. Case study: on the relational integration between emergency physicians
and medical specialists of other departments and the influence on the patient flow at the ED. Unpublished master’s thesis, University of Groningen, Groningen, The Netherlands.
Sims, S., Hewitt, G., & Harris, R. 2015. Evidence of collaboration, pooling of resources, learning and role blurring in interprofessional healthcare teams: a realist synthesis. Journal of
