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Abstract
Background and objectives As interest in doctors' work in Germany has increased over the last few years, this study determines how doctors spend their work time in emergency departments. The study also provides information on patient load and working conditions in emergency units.
Methods and material An observational time-and-motion study was carried out at three emergency departments. A single investigator followed emergency doctors and recorded the time spent on various work activities. Job activities were classified into 12 different main categories, including direct or indirect patient care.
Results The data showed that doctors in emergency departments had to work overtime (M=09.17 h). They performed more than 80 tasks per day and were forced to handle multitasking situations. Indirect patient care and administrative duties were the main tasks doctors spent time on during the day. Direct patient care and contact represented only a small proportion of work time.
Conclusion Doctors working in emergency care units have to deal with highly unpredictable workloads and overtime work, and simultaneously should also care for patients and interact with a large number of different persons during each work shift. The findings of this study are useful in efforts to improve emergency medical care and doctors' working conditions.
- Emergency care
- patient load
- job satisfaction
- work strain
- emergency care systems
- ethics
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Introduction
The medical specialty ‘emergency medicine’ is characterised by immediate medical help and awareness for patients with acute illnesses or injuries.1 ,2 Emergency medicine doctors have to deal with a variety of illnesses and undertake acute interventions to stabilise the patient. Doctors working in emergency departments have to deal with a demanding field of medicine.3–5 This means working in a high-stress environment, handling high-pressure situations, and providing a fast and correct diagnosis and urgent care. Complete or 100% involvement of the attending doctors is expected.
Over the past years, the healthcare system in Germany has undergone significant changes. Medical structures have changed under the pressure of economic and restrictive healthcare policies.6–9 Shorter hospital stays, high patient loads/frequencies and increased bureaucratic duties lead to high workloads and working under pressure.7 These changes within the medical profession have led to dissatisfaction among doctors in Germany10 and affect their work efficiency as well as the quality of care.9 ,11 Dissatisfied doctors are more likely to leave their clinical jobs to seek work abroad or other opportunities.
Because of these recent changes in the healthcare system in Germany, there has been tremendous interest in examining how doctors spend their working time at hospitals in Germany, with specific attention paid to how effectively they work.
However, very little is known about working conditions in emergency departments in Germany in general, as few attempts have been made to examine these conditions. Most studies examining these conditions have been based on subjective perceptions (questionnaires) of healthcare employees, and the results have yet to be corroborated by data from objective time–and-motion studies.
Currently, a comparison of previous studies is limited by methodological differences regarding data sets, sample criteria and methods. Previously, we conducted observational studies examining the working conditions of doctors in the fields of internal medicine, neurology, geriatrics, paediatrics and psychiatry.12–19
This study was designed to examine the working conditions and job satisfaction of doctors working in emergency departments. This may also allow a comparison with other medical fields. In addition, it helps describe an emergency department workplace in Germany. This might be helpful in developing interventional strategies (eg, organisational restructuring) that may reduce workloads in emergency care departments.
The main objectives of this investigation were to determine the following:
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The amount of time doctors in emergency units spend on different daily clinical activities.
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Their workload in terms of work hours, patient load, interruptions and multitasking.
Methods
Study design, setting and selection of participants
Doctors' workflow was analysed using a cross-sectional study design. We carried out an observational time-and-motion study. Data were collected from June 2010 to October 2010 in three emergency departments in Berlin, Germany. Twenty-five emergency doctors were recruited from three urban hospitals. An email enquiry was sent to eight hospitals in Berlin/Brandenburg in the beginning to select appropriate and comparable partners.
Factors for screening hospitals were size of the hospitals (nearly the same size), number of beds (not more than 500), and doctors and nurses specialised in emergency care.
Consent was received from the emergency departments invited to participate in this study. Afterwards we obtained a list of names of all doctors working in each emergency department. A group of emergency doctors was randomly selected and participation in the study was voluntary. We randomly selected a doctor on the list and spoke to him or her, asking whether he or she would like to participate in our study (verbal consent). In addition, the whole hospital staff was informed about the main aims and content of this study. We assured everyone that all data would remain both anonymous and confidential.
Each emergency doctor was observed throughout four entire weekday shifts (Monday–Friday; starting from 08:00 until the doctor's shift was over). For inclusion in this study, some factors were important: participants had to be doctors working in an emergency ward, and they had to have tenured work contracts and at least 6 months of work experience.
Data collection software
A special job task classification system for emergency medicine was developed. Expert interviews were carried out in advance to know what kind of job tasks should be implemented. A software was programmed and incorporated/installed into an ultra mobile PC (a wireless handheld computer). The observer recorded all work tasks in real time via touch screen modus. Every job activity selected from the classification system was automatically and exactly recorded as a time value using an access database. Our software also allowed recording interruptions defined as an ‘interruptive event’, leading to cessation of the present job task. Multitasking activities (if the participant was observed to perform two tasks at the same time) were also recorded. Since quick rotation of tasks and frequent interruptions are commonplace in an emergency setting, this multidimensional task categorisation system is a precise way of recording such data.
The work task classification was developed on the basis of information from experts' interviews. Experts were residents working in the emergency care units. The objective of the classification was to cover all activities performed in an emergency unit within 12 major categories (table 1). Task categories included (1) patient care such as medical examinations, (2) indirect patient care, (3) patient admission, (4) meetings, (5) doctor–patient conversations and (6) administrative and other tasks (see table 1).
Names and definitions of job tasks performed by the observed doctors
Pilot study
Before collecting data, we carried out an observer training (during two entire work shifts) to acclimate each researcher to the classification system. Therefore, an emergency doctor was observed and tasks were recorded by two different researchers at the same time but observing independently of each other. To test for interobserver reliability, the work shifts of a doctor were observed by two examiners. Reliability testing revealed an interobserver reliability of more than 85% (95% CI 72% to 89%). In addition, the task list was revised during the observer's training.
Data collection procedure
The observer followed each emergency doctor continuously/permanently to all locations (except the bathroom) over four entire work shifts, recording all activities he or she performed during the day. The researcher was not allowed to end the observation until the doctor being observed stated the work day was over so that overtime hours could also be analysed. To minimise the Hawthorne effect, participating doctors were not informed about the categories in the task classification system. In addition, the investigator tried to stay in the background or at a distance of at least 3 m from the doctor. Moreover, the observer was not allowed to initiate conversation with the participating doctor.
In total, we carried out 100 8-h observation periods in emergency departments.
Statistical analysis
Data were collected by an access database and automatically incorporated into an Excel spreadsheet for analysis. Descriptive statistics (ie, mean and SD) were used to illustrate job tasks performed by the participating doctors. The number of interruptions and the amount of multitasking observed were also analysed. Twenty-five units of analysis were used in the calculation (as mean distributions of work tasks per participant). For analysing distributions of time spent on certain work tasks, descriptive statistics were calculated for all task categories as well as for the rates of interruption and multitasking.
Results
Demographic characteristics of participants
Twenty-five emergency doctors (15 male and 10 female) were observed during 100 work shifts. On average, the participating doctors were 32 years old (SD=3.7 years). The average work experience was 3.9 years (SD=3.1 years). All participating doctors worked full time.
Activities performed by doctors
In total, 100 working shifts (821 h of work activity) were recorded during the study period. Doctors performed 85 different tasks per day on average and 29 interruptions were recorded during a typical work day.
On average, 32 walk-in/first-aid patients were admitted to an emergency department (SD=6).
The distribution of time spent on different job tasks is illustrated in figure 1. The average working time per shift was 09:17:34 h (95% CI 08:44:23 h to 09:53:54 h). A mean of 31 min is spent for rest periods during this time (95% CI 00:25:34 h to 00:37:32 h).
Distribution of work activities.
The tasks performed most frequently in each observational period were meetings and internal communication, administrative tasks and indirect patient care (see figure 1).
On average, the time emergency doctors spent on patient care tasks was 88% per day. The proportion of working hours doctors spent unrelated to patient care was 12% on average per day.
No significant differences were found between the observed doctors with regard to differences in training levels.
Meetings and internal communication
The biggest single proportion of the working day was spent on meetings and internal communication, amounting to an average of 02:23:14 h (95% CI 02:11:24 h to 02:51:25 h) per doctor (see figure 1).
Doctors in emergency departments spent 00:38:13 on phone calls (95% CI 00:35:59 h to 00:44:56 h) (eg, exchanging patients' information, demanding medical reports or ordering/scheduling further specific medical examinations).
Another 10% of an average working week was spent on supervising medical students (SD=9.5%).
During the working week, doctors had 00:51:24 h on average for advanced training (95% CI 00:39:23 h to 01:09:51 h).
Administrative tasks
Doctors spent 21% of coded time performing documentation tasks across all shifts (SD=10%). These administrative activities mostly centred on writing doctors' letters for an average time of 01:02:11 h per day (95% CI 00:48:54 h to 01:17:32 h).
Indirect patient care
Time spent on indirect patient care was another large time commitment. Overall, each doctor spent an average of 01:24:17 h daily (95% CI 01:15:21 h to 01:51:29 h) for indirect patient care. This main category includes transporting patients, literature research, changing infusion plans and re-evaluation of findings.
Time for medical examinations
The daily mean duration for medical examinations including functional diagnostic procedures was 00:51:38 h per day (95% CI 00:44:13 h to 00:58:13 h).
Medical examinations for which a doctor's qualification is not required (eg, taking blood samples) accounted for 00:09:43 h on average per day (95% CI 00:07:23 h to 00:15:13 h).
Exchanging information (ie, about the patient) lasted on average 00:27:24 h per day (95% CI 00:23:42 h to 00:35:42 h).
Time for medical examinations must be differentiated between types of patients.
The amount of time spent on direct medical service provided to patients requiring critical care differed significantly from that spent on services provided to patients without severe/life-threatening symptoms. Thus, the extent of medical care/service provided was correlated with the severity of the disease/ patient's health status and varied among patient groups. The intensity of service was lower in patients being observed in intensive care units than in other patients.
Anamnestic examinations did not differ by level of experience. No significant differences were found in the duration of taking medical history and completing medical examinations, regardless of the participating doctor's experience.
Time for admission to hospital
A doctor working in an emergency unit spent 00:45:56 h on daily admissions to the hospital (95% CI 00:37:15 h to 00:54:23 h). Depending on the type of disease or injury or sickness, the average time for admission measured in this study varied notably.
Communication with patients and family
On average per day, a doctor spent 00:38:54 h communicating with his or her patients (95% CI 00:21:23 h to 00:51:52 h). This category includes diagnostic and therapeutic conversations, as well as psychological and medical explanations. The mean number of doctor–patient interactions varied according to the patient's actual status. Most patients had at least one or two interactions with a doctor. Duration of interactions varied between 00:03:12 and 00:10:23 h on average.
Talks with the patient's family and relatives lasted 0.5% of a typical work shift (SD=1.2%).
Additional time
Obstacles at work such as computer problems, waiting for colleagues and/or patients, or searching for necessary paperwork lasted on average 00:10:00 h (95% CI 00:07:25 h to 00:12:54 h) of the daily working time.
Personal hygiene (such as hand washing and sterilizing) consumed 00:05:21 h per day on average (SD=00:04:23 h).
Miscellaneous activities (such as changing working clothes and personal activities) lasted on average 00:14:52 h (95% CI 00:10:54 h to 00:19:42 h). The observed doctors were found to spend 00:53:23 h (95% CI 00:41:23 h to 01:02:34 h) of their daily working time for walking within the hospital.
Multitasking activities
Multitasking was observed quite often in emergency units. The time spent on simultaneous tasks was mainly detected as indirect patient care, conversation and direct patient care. The most common simultaneous work task combination was documentation and exchanging patients' information with colleagues. This multitasking combination was carried out for 00:11:02 h on average per day (SD=00:12:43 h). Of the whole work day, 23% was spent on doing two job tasks simultaneously (SD=12%). No significant difference was analysed between male and female doctors or doctors with different levels of experience.
Interruptions
Another phenomenon observed was the large number of interruptions that doctors in emergency departments faced. On average, emergency doctors were interrupted once every 00:11:00 h. A precise understanding of the impact of interruptions was gained by determining the frequency of interruptions per day (see figure 2). Emergency doctors were interrupted on average 24 times during each working day (SD=9.3). No significant differences were found among doctors included in this study.
Number of interruptions during the work day.
Discussion
The aim of this study was to analyse objectively the work activities of emergency care doctors. Our study represents the first adequate documentation and evaluation of the working conditions of doctors in emergency care units in Germany.
Working hours
Our findings demonstrated that doctors work more than 42:00:00 h per week and confirm that work schedules might be unpredictably prolonged.
Similar results regarding work hours have been found in other work analyses.20 ,21 Work hours lasted on average longer than 09:00:00 h per day. This result is comparable to other studies illustrating working hours between 65:00:00 and 85:00:00 h per week in international emergency departments.22–24 Working overtime was cited as an argument for job dissatisfaction among residents.25–27
Recent studies demonstrated that stress from work overload has important consequences on productivity, quality of task performance, workplace anxiety, fatigue and job satisfaction.21 ,28
Within these observed working hours, too much time was spent on indirect medical care and administrative duties. In contrast, less time was spent on individual patient care and contact. The shortage of time for direct patient care and contact has considerable negative consequences for medical outcomes, treatment and quality of care.27 ,29 ,30
A possible solution might be the restructuring of job activities and establishing a more convenient digital record system to reduce the burden of administrative duties. In addition, electronic systems for medical records and electronic order forms for doctors may be potential time-saving measures to increase the time available for direct patient care and to improve work efficiency in general.27 ,31
Patient load
The results of our study confirm previous data that working in an emergency department means having to treat a large number of patients with a large variety of complaints on a daily basis.
High case loads are challenging, especially for doctors with less experience, and can lead to overwhelming feelings of time pressure, inadequate clinical performance and long work days.32–35
Studies have shown that overcrowded emergency rooms contribute to job strain, fatigue and burnout.36 Despite heavy patient loads, doctors in emergency departments have to offer life-saving healthcare within limited resources at all times.
Interestingly, patient load was characterised with variability. Sometimes doctors had to cope with a heavy patient load, all patients arriving at the department at the same time. At other times, doctors were more relaxed because there were fewer patients. During the observational period, the observed doctor was more relaxed and had enough time for every single patient.
Summing up, our data show that the patient load in emergency departments is uncontrolled and unpredictable.
Communication with patients, relatives and colleagues
Our study results demonstrated that doctors spent only a little time per shift on direct patient communication in an emergency department.
These data corroborate the finding of various studies14–16 ,18 ,19 ,37 and were remarkably similar to the results reported in other medical fields.12 ,15 These results are also similar to data examining the activities of doctors in internal medicine, which found that 22% of their time was spent on direct patient care.18 All studies reported that in hospitals most of the doctors' time, particularly most of the residents' time, was spent on indirect patient care and on administrative activities. Surveys on patient satisfaction showed that the main reason for dissatisfaction with medical care in emergency medicine was insufficient communication between patient and doctor. Patients often complained that too little time was spent on clarifying informational conversation (diagnostic and therapeutic talks).38–41 Many patients who were admitted to emergency care units had severe illnesses or injuries. Surveys illustrated that they often felt alone and helpless in emergency departments.42 ,43 Previous findings showed that efficient and emphatic conversation with the attending doctor improved and accelerated convalescence and also calmed shocked patients.44
In addition, it is necessary to explain medical symptoms and recommended treatment to accompanying persons and/or family. Quite often they are desperate, anxious and depressed and worrying about their family member. One of the tasks of a doctor is to clearly and precisely clarify facts in detail.
Future doctors should focus more on individual communication with patients and their relatives. In addition, constant training on how to communicate with patients and their families might be an asset.
Communication with colleagues and hospital staff
Our results illustrate that doctors interact with a lot of people (eg, other doctors, nurses, paramedics, etc). We observed that quite often this creates interruptions in work tasks and, as a consequence, problems in transfer of information. One problem could be seen in information gaps occurring when misunderstandings exist; information is unavailable or not communicated to others. As a consequence, wrong medical decisions and an unsatisfactory healthcare could result. Decreased quality of patient care, patient dissatisfaction and medical errors can be associated with insufficient communication.44
In addition, deficient communication and transfer of information in the emergency department probably raise the direct costs of medical care because of the need to repeat medical examinations and diagnostic procedures. Better communication between doctors and other hospital staff and units could help avoid medical problems and ensure a good quality of care in emergency medicine. Interventions such as communication training and implementing an online patient information system might be helpful in improving medical procedures and outcomes of medical care in emergency departments.
Interruptions
Our study results have also shown that interruptions in emergency departments are very frequent and many of these interruptions resulted in breaks in the main task.
The amount of interruptions found from our study is comparable to that from previous investigations.45–48 A study by Spencer and colleagues49 illustrated 23.5 and 8.3 interruptions per hour for emergency department doctors.
Although it is well known that emergency rooms have to function at a fast pace, too many interruptions and multitasking can result in disastrous medical errors. Research is beginning to show that excessive interruptions cause medical malpractice too.47 ,48
Previous study data illustrated that it is quite stressful for emergency doctors to focus on the care of one patient while being constantly interrupted.
Electronic medical record systems may help in handling interruptions. These systems could be very useful in saving time while waiting for phone calls and other reports and communications from specialty doctors, etc. This would help doctors spend less time on other activities and more time on caring for and communicating directly with patients.
Multitasking
Another important finding of our study was the magnitude of multitasking in the workplace. Our results provide evidence supporting doctors' self-reported working conditions in the form of a quantitative workflow analysis.
Doctors were involved in simultaneous tasks such as examining a patient while talking to a colleague. Treating different patients at the same time was another phenomenon noted in our study.
A recent study found that in an emergency department doctors often have to treat more than 12 patients simultaneously.48
In general, doctors report a high level of stress due to multitasking. Similar to the findings of previous studies, doctors in our study spent the main part of their time multitasking.26 ,27
Earlier research found that multitasking could result in severe medical errors or incorrect decisions on medical care.50 Regarding consequences for patient outcomes, hospital management need to rethink the way in which their emergency departments are organised and administered efficiently in order to reduce the risk of medical errors.
Limitations
The results of our study must be interpreted in the light of several limitations that might affect the generalisability of our results.
Although we collected the data from several hospitals in Germany, these data are not representative of the workflow of all emergency doctors in Germany. A larger cohort is necessary to provide more general applicability of the results.
In addition, there is a slight chance of observational bias. The presence of an observer might influence the behaviour of the participant and the activity patterns of the observed doctor (Hawthorne effect).
Despite these limitations, the actual study has shown evidence of being a qualified method to collect substantive data about the working conditions in emergency departments.
Conclusion
This study is the first of its kind to examine the working activities of junior doctors in cardiology departments of hospitals in Germany. The study results illustrate serious deficits in doctors' working conditions: working overtime, heavy patient load, multitasking, work-related obstacles, etc. These working conditions have been described as predictors of stress and dissatisfaction among junior doctors.10 ,51–54
Several studies illustrated the coherence between the workload of doctors and their job and life satisfaction.55 To improve this situation, organisational procedures should be reorganised and the implementation of electronic systems is strongly recommended. In this way, doctors in emergency departments can spend more time on direct patient care treatment and will be more satisfied with their jobs.
Thus, the findings of this study may be useful in improving the work, working conditions and work efficiency of emergency doctors.
References
Footnotes
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Competing interests None.
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Ethics approval Free University of Berlin/Humboldt University of Berlin.
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Provenance and peer review Not commissioned; externally peer reviewed.