'Thick divide' still exists between many ED staffs
Lack of understanding, respect cited
When the pressures of working in the highly charged atmosphere of the emergency department (ED) collide with the internal "caste" system often created by staff, the situation is ripe for conflict between nurses and ED registration staff.
Despite the "phenomenal job" being done at many facilities to bridge the gap, Shawn Glinter, RN, MBA, says he often feels "a thick divide between registration and nursing" when he walks into an ED.
"Staff have been forced to behave a certain way and curtail certain behaviors, and there are statutory requirements; but in many cases problems still exist," adds Glinter, who began his career as an ED nurse and has worked as an administrator with oversight responsibility for both clinical and access employees in the ED.
Each side understandably has its own agenda and is focused on the job to be done, he says, but in many cases the real conflict comes from a lack of understanding and respect between clinicians and access personnel.
During his years in the ED, he has observed a "turf war" that probably stemmed from the failure of nurses to acknowledge the importance of the access role, says Glinter, who now works for a health care technology company. "It's a lot easier for patient access to understand the nursing side."
He recalls being frustrated early on with requirements that seemed to interfere with the care of patients: "Who knew you couldn't just order labs without getting patients into the system?"
In addition, Glinter points out, there are cliques within the medical profession that can spill over into the access arena. "It's a culture," he adds, noting that nurses create a kind of hierarchy within their own ranks in which trauma and cardiac critical care nurses, for example, consider themselves the "cream of the crop."
As an extension of that, Glinter says, ED nurses can "look down" on registration personnel because of a disparity in educational levels — not to mention the feeling that they're "saving lives and making a difference" while the mission of those on the business side is not as lofty.
In one of the facilities where Glinter worked, he notes, the situation had deteriorated to the point that ED access staff requested an employee lounge of their own because employees in the back would throw out their food.
"It really comes down to common sense and courtesy and mutual respect," Glinter says. Crucial to creating that kind of inter-staff relationship is an attitude of respect for access that filters down from top management, he adds. "Lead by example; if nursing and patient financial services are at odds, you've got an uphill battle."
Encourage a culture of mutual support, Glinter suggests, by celebrating successes together. "If the department decreases wait times, reward the entire staff. Don't have a Christmas party where the medical staff does its own thing and patient access does its own thing."
Successes exist when there is a clear understanding that both roles are important, he says. "That has to do with education.
"One of the things I have done, as a part of orientation, is have new ED nurses spend about three hours with an ED registration supervisor or manager, and vice versa," Glinter says. "As part of orientation for ED registration, we let [new employees] shadow a nurse for a shift. It brings awareness.
"When you do things repetitively, and say, 'This is how it's going to be,' it's effective," he notes. "You have to stand your ground."
To foster a good working relationship with "the other side," ED access managers should take the first step with their clinical counterparts, Glinter suggests. "If it's your first week on the job, go introduce yourself. Have coffee or lunch with the charge nurse."
There is a tendency in health care to say, "'We've done it this way for 20 years, we'll do it for the next 20 years,'" he adds. "It's important to break down those barriers."
Invite nurses to staff meetings
Invite charge nurses to the monthly staff meeting for ED registration, and ask them to let you come to their meeting, Glinter continues. "No matter how many degrees [each has], neither can do the job without the other."
When Glinter worked as an associate administrator with responsibility for patient access and the ED, he says, he required that access and clinical managers attend each other's meetings. "You don't always have to participate in the conversation, or if there is a lot to cover, you don't have to be there for the entire meeting."
There are inherent challenges that come with inter-staff team building in the ED, Glinter concedes. "ED registration is one of the hardest jobs in health care. It's really stressful, and it takes a certain kind of person, not just access experience.
"You've got a unique situation," he adds. "Patients come in sick and scared, and you make them wait a long time and then take off their clothes and wear a paper gown. After four to six hours they leave, and you charge them a lot of money."
As an access employee, Glinter says, "you may be registering a patient who is bleeding or vomiting or yelling at you."
He recalls an incident at one facility in which the registrar had her head down as the next patient approached and just said, "Sign here, what's your insurance?" When she did look up, Glinter says, she saw that the patient had a paring knife in his stomach.
"We're paying $7 to $14 an hour, so what are we going to focus on in orientation: How to get the patient in the system, how to put a chart together, which physicians to look out for."
Even so, hospitals are getting better at preparing their ED registrars and facilitating cooperation between them and their clinical counterparts, he says. "Where you see the gap being closed is where management feels that it's a core competency. Some have good inter-staff relations as one of their performance objectives. They look at it as part of the job evaluation."
[Editor's note: Shawn Glinter can be reached at (615) 491-3270.]
When the pressures of working in the highly charged atmosphere of the emergency department (ED) collide with the internal "caste" system often created by staff, the situation is ripe for conflict between nurses and ED registration staff.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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