Simon Craig, FACEM, GCHPE, Emergency Physician and Director of Emergency Medicine Training, Adjunct Senior Lecturer; Jonathan Dowling, FACEM, PgCertTox (Cardiff), Emergency Physician and co-Director of Emergency Medicine Training, Adjunct Lecturer.
Correspondence: Dr Simon Craig, Emergency Department, Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168, Australia. Email: firstname.lastname@example.org
In Australasia, emergency registrars usually gain experience ‘running’ an ED overnight – without supervision. This paper describes the introduction of FACEM-supervised daytime ‘registrar in charge’ (RIC) shifts into a tertiary adult ED over a 6 month period.
Each registrar was allocated at least one RIC shift during their 13 week ED term. Structured questionnaires gathered data regarding the educational impact of the shifts, any adverse effects on departmental function, changes to work practices, and perceptions of teaching and learning. Data were analysed using thematic analysis.
During the study period, 16 senior ED registrars were rostered for 26 RIC shifts. Questionnaires were completed by 16/16 registrars and 13/16 emergency physicians. The RIC shifts were viewed positively by the emergency registrars – 93% reported useful feedback, felt that the shifts provided a good insight into their workplace behaviour, and that they should be rolled out across other departments. FACEMs were also positive in their evaluation, and reported little negative impact on departmental function. Major themes identified by both registrars and emergency physicians included communication skills, knowledge and experience, delegation, professionalism and organisational skills. Additional themes that were more prominent in FACEM responses included multitasking, dealing with interruptions, managing patient flow and being aware of the whole department.
RIC shifts are a feasible and acceptable method to teach running the floor in the ED. Further study should assess impact on patient outcomes.
Smooth coordination of the day-to-day work in the ED is vital to ensure timely and high-quality care. The role of ‘shop floor leader’ in an ED is often shared between an emergency physician and the charge nurse, and is central to patient safety. Senior ED doctors undertake various important tasks during a shift ‘in charge’ – these include clinical problem solving, clinical supervision, teaching, and communicating with patients, family members, hospital staff, medical administrators and prehospital providers.
Graded responsibility and progressive independence from supervision are basic principles underlying any specialty training programme. By the end of their training, an emergency physician should possess the necessary leadership, supervision and delegation skills to safely coordinate and oversee the simultaneous management of multiple patients. Increasingly, these skills will be practised in an overcrowded, high-pressure environment with limited resources.[6-10]
Emergency physicians supervise doctors of varying skill and experience: emergency medicine registrars, career medical officers and prevocational junior doctors. The most senior doctor in the department varies, although in most metropolitan hospitals a FACEM oversees patient care and provides supervision and advice to junior doctors during day and evening shifts. Senior emergency medicine registrars are often in charge of the department overnight, without direct supervision by an emergency physician.
Emergency medicine trainees traditionally learn departmental management skills without supervision by FACEMs. Experienced charge nurses provide significant guidance, particularly when registrars first ‘step up’ to be in charge overnight.
A review of the literature did not identify any previously published reports describing educational programmes aimed at the ‘in charge’ role. This paper describes the introduction of, and the clinical and educational impact of, such a programme.
This pilot study was undertaken at Monash Medical Centre, a tertiary hospital in the south-east of Melbourne, Australia, between September 2011 and February 2012.
The ED at Monash Medical Centre has over 71 000 attendances per year. Adult and paediatric patients are cared for in geographically distinct areas in the ED, which have separate staffing. The adult ED has 26 cubicles (with an additional 10 short stay beds), and sees approximately 46 500 attendances per year, with an admission rate (ward and short stay unit) of 48%. There are 21 FACEMs employed by the department (full-time equivalent of 15), and junior medical staff is comprised of 10 senior registrars, 11 junior registrars and 14 prevocational junior doctors.
The ED has FACEM staffing from 08.00 hours until midnight every day. Overnight, the department is staffed by senior registrars, most of whom are ACEM trainees. The training level of the senior registrars varies from those who are approaching fellowship examination and a subsequent specialist qualification, to those who are just entering the 4 years of advanced training in emergency medicine. Most have completed 3 month terms in both intensive care and anaesthetics.
Before the introduction of the pilot programme, the ED had 5 h of rostered didactic sessions for registrars each week, and also offered one-on-one clinical teaching shifts where a registrar was shadowed for a 2 h period by a FACEM for the purposes of direct observation and specific feedback on their clinical practice.
During the study period, the ED introduced a new form of clinical teaching. Senior registrars were assigned to be ‘in charge’ of the ED during the start of a day shift, and work directly under supervision of a FACEM. The aims of this programme were to improve the registrars' skills at departmental management (particularly on night shifts), and to foster improved teamwork between the registrars and other ED staff (particularly the nurse in charge).
The duration of the ‘registrar in charge’ (RIC) shift was determined by the judgment of the supervising FACEM, and the departmental workload. Most shifts lasted from 08.00 hours until around midday; however, the shift could be shortened if the department was particularly busy or short-staffed because of sick leave.
A purpose-designed survey was developed using Surveymonkey™ (Palo Alto, CA, USA) to evaluate the pilot programme.
Questions were asked for respondents' views on whether the RIC shifts provided a good insight about workplace behaviour, utility of the feedback provided, perceived impact of the shifts on the department, whether the shifts should be continued, and willingness to be involved in further RIC shifts.
Registrars were also asked open-ended questions about whether they had made any changes to overnight work practices as a result of the RIC shifts, and whether they discovered anything unexpected as a result of the shift. Senior medical staff were asked about their perceptions of learning during the shift, and what they were aiming to teach. All respondents were also asked questions regarding their perceptions about important qualities required to run an ED, and suggestions for improvement to the teaching programme. The questionnaire was trialled among a group of FACEMs and revised before being used in the study.
The study was approved as a quality assurance activity by the Southern Health Research Directorate.
The survey was distributed via email to registrars and senior medical staff. A single reminder email was sent 2 weeks after the original request.
Survey responses were downloaded onto a password-protected Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA). Data were analysed using the Stata version 8.0 statistical package (Stata Corporation, College Station, TX, USA). Categorical descriptive data are presented as number and percentage. Comparisons between groups were performed using Mann–Whitney two-tailed t-tests where appropriate. As this was mostly an exploratory and descriptive study, a power calculation was not performed.
Qualitative analysis was performed using thematic analysis. One author (SC) read through and analysed all free-text answers to identify patterns of responding. Themes and categories emerged on close examination of full-text responses, and were identified in view of their high frequency of occurrence. The data were read repeatedly. Data with similar content and meaning were grouped categorically. Analysis was continued until all possible themes were identified (thematic saturation). Categories were refined through comparable responses, based on the level of concordance of responses.
The authors attempted to adhere to previously published recommendations for improving the rigour of qualitative research – particularly emphasising aspects of credibility, transferability, dependability and confirmability. The survey was designed to focus the respondent's attention on various aspects of being in charge of an ED, which enabled analysis of free-text responses to occur in discrete groups. Analysis was undertaken by an emergency physician with previous experience in thematic analysis; additional member checking of responses did not occur.
The survey was completed by all 16 registrars, and 13 of 16 emergency physicians (response rates of 100% and 81%, respectively).
Of the registrars, 14 were ACEM trainees (13 advanced trainees and one provisional trainee), one was an intensive care trainee, and one was a paediatric trainee undertaking joint training in emergency medicine. All emergency physicians held FACEM qualifications, and had been working in the ED for times varying between 1 year and 18 years.
Of the 16 trainees, 15 experienced at least one RIC shift. One shift was cancelled because of significant staffing shortages on the scheduled day. Most trainees had one or two shifts during the study period, although one had three shifts and one other had four.
The registrars and FACEMs were positive in their evaluation of the RIC shifts (Table 1). The majority indicated that the shifts provided a good insight into registrars' workplace behaviour, that the shifts should be continued, and that they should be rolled out into other EDs in the local clinical network. In addition, all respondents stated that they would be willing to be involved in further shifts. Registrars viewed the shifts as relevant to their learning needs, and a source of useful feedback.
Table 1. Responses to the survey questions
Emergency trainees (n = 15)
Emergency physicians (n = 9)
Strongly agree or agree
Disagree or strongly disagree
Strongly agree or agree
Disagree or strongly disagree
EP, emergency physician; MMC, Monash Medical Centre (the study hospital); NA, not applicable.
The shift provided me with a good insight into the registrar's workplace behaviour
The ‘registrar in charge’ shifts should be continued at MMC ED
The ‘registrar in charge’ shifts should be rolled out across all Southern Health EDs
I would be willing to be involved in further ‘registrar in charge’ shifts
On the days I have done the shift, there has been a NEGATIVE impact on the department (EP only)
The shift was relevant to my learning needs (registrar only)
The feedback I received during/after the shift was useful (registrar only)
The majority of senior medical staff felt that there was no negative impact on the department during the shift.
Figure 1 indicates that there was a range of opinions on the optimal duration for the RIC shifts. Registrars felt that the RIC shifts should last at least 6 h, whereas FACEM opinions ranged from 2 to 10 h.
Registrars and FACEMs agreed that RIC shifts should not be offered to junior medical staff (Table 2). They felt that senior registrars (i.e. those who are expected to be in charge of the department overnight) should each receive two or three shifts per 13 week term. This estimate did not change when respondents were asked to consider whether the registrar had worked at our institution previously. There was no statistically significant difference between FACEMs and registrars for any estimation of optimal number of shifts.
Table 2. Respondents' median estimates of how many registrar in charge shifts should be offered each 13 week term
aP-value calculated using Mann–Whitney two-tailed test. MMC, Monash Medical Centre (the study hospital).
Senior registrar – not worked at MMC
Senior registrar – previously worked at MMC
Overall, 103 free-text responses were analysed, 59 from registrars and 44 from emergency physicians. Responses about the RIC programme in general were positive: most respondents either gave positive feedback, or requested more frequent RIC shift opportunities of longer duration. Other suggestions included specific learning objectives to be provided before the session, and to ensure that the department was adequately staffed.
Registrars did not identify many significant changes in work practice or discovery of unexpected aspects of being in charge of the department. Major issues raised included multiple interruptions (phone referrals, supervising junior staff, less time to see patients and a perception of less patient safety), an improved awareness of factors influencing patient flow, and the need for regular communication with the nurse in charge of the department.
Emergency physicians felt that the most important concepts to teach during the shift were:
Communication and diplomacy
Multitasking and dealing with interruptions
Awareness of the ED as a whole
Communication with the nurse in charge
Resource allocation and patient flow
Supervision and looking after junior staff
When analysing responses regarding perceptions about important qualities required to run an ED, three main themes were identified: interpersonal skills, management skills and clinical skills. Various subthemes were identified within each main theme, and there were some differences in emphasis between FACEMs and registrars.
Major themes that were common to registrars and FACEMs included communication skills, knowledge and experience, delegation, professionalism and organisational skills. Additional themes that were more prominent in FACEM responses included multitasking, dealing with interruptions, managing patient flow and being aware of the whole department. Registrars emphasised the importance of looking after fellow staff members, and communicating with the nurse in charge. Representative quotes are provided in Box 1.
Box 1. Representative quotes for perceptions of important qualities required to run an ED
‘Clinical knowledge. Ability to work under stress. Multitasking. Ability to supervise and follow up each case. Knowledge of hospital's protocols & bed management’
‘Friendly, helpful. Good leadership, organized, able to cope with stress. Humility. Able to think fast’
‘Sound knowledge of management of all emergency conditions; Good understanding of the logistics of arranging investigations & following up of patients within and outside [the hospital] … Ability to supervise junior medical staff … Ability to deal with unexpected and stressful situations … Ability to work with nursing and non-medical staff in managing the department and allocating resources appropriately’
‘Communication Multi-tasking Diplomacy’
‘Multi-tasking, able to think about the whole department. Ability to remain calm. Ability to get critical information from junior staff. Ability to cope with constant interruptions’
‘Able to maintain a calm demeanor, and encourage others to do the same. Multitasking and being able to focus despite multiple distractions and interruptions. Good communication with the nurse in charge.’
‘Departmental awareness … Knowing what is going on in the department and in the waiting room. Solid knowledge base. Awareness of staff abilities/capabilities – allows you to delegate tasks appropriately.’
‘Good listener and good communicator. Awareness of patient flow and access issues, with timely escalation to management’
The International Federation of Emergency Medicine (IFEM) suggests that by the end of training, emergency physicians should be expected to ‘possess a comprehensive knowledge of emergency care and the emergency procedural skills to manage common acute medical and surgical problems’.
The CanMEDS 2005 Physician Competency Framework states that the Medical Expert Role is ‘central and integrative’ to postgraduate medical training. The Medical Expert Role sets physicians apart from other professionals, and most training programmes focus on ensuring appropriate education in this area.
A recent survey of US-based Emergency Medicine Residency programme directors reported that although most programmes provided education about documentation and billing/coding, a smaller proportion taught day-to-day management and operations of the ED. Other publications have focused on the potential efficiency gains of individual practitioners;[16, 17] however, there is little information in the medical literature about learning how to manage the floor of a busy ED.
A comprehensive learning needs analysis of Australasian emergency physicians highlighted that day-to-day departmental management and administration might be a source of considerable frustration, and was identified as a highly desirable topic for continuing medical education. A survey of Canadian emergency physicians also demonstrated a need for education in aspects of the Manager role, including patient flow strategies.
There is an increasing recognition by academic bodies of the need to explicitly address this aspect of training. The UK college of emergency medicine provides detailed outlines of competencies for ‘time management and decision making’, ‘decision making and clinical reasoning’, ‘team working and patient safety’ and ‘communication with colleagues and cooperation’. A recent review of the ACEM curriculum recommended various domains of practice, including prioritisation and decision making, teamwork and collaboration, and leadership and management.
The IFEM model curriculum includes the following learning objectives for postgraduate emergency medicine training:
Develop the skills of delegation to other personnel in the emergency department and the leadership skills required to maintain the pace of others working in the clinical environment to ensure that patient needs are met
Demonstrate the capacity to prioritize attention to those patients with more urgent condition
Clearly, departmental leadership is an essential skill for an emergency physician. This leadership not only encompasses medical leadership, but also involves varying degrees of oversight of nursing, allied health and other non-medical staff. It is likely that the complexity of leadership will increase with the introduction of physician assistants and other professionals who are able to perform traditional medical tasks.
This paper provides the first available data describing the teaching and learning of how to run an ED. Although it was conducted in a single centre with small numbers of trainees, the data provide some insights into this educational process.
The free-text comments from our study participants provide an insight into the differences in perception between registrars and experienced FACEMs regarding the ‘in charge’ role. Emergency physician responses highlighted the importance of multitasking, dealing with interruptions, managing patient flow and being aware of the whole department. These concepts should be considered when designing a curriculum, as they were not emphasised in the registrar responses.
The introduction of RIC shifts to our ED was prompted by a perception that registrars would benefit from specific education on leadership and departmental management. In view of previous studies describing successful teaching and assessment of non-Medical Expert competencies using direct observation,[24-28] we designed our programme to use an emergency physician to observe, provide feedback and demonstrate positive role modelling.
The results of our pilot programme suggest that this teaching method is feasible (so long as departmental staffing is adequate), provides relevant learning opportunities and encourages useful feedback to registrar staff. It also proved popular with both FACEMs and registrars. Additionally, we have identified that FACEMs and senior registrars have some differences in their perceptions about important qualities required to run a busy ED. These findings, if replicated in other settings, might provide information to those seeking to deliver focused education on this aspect of emergency medicine training.
Since the pilot programme, we have continued the RIC shifts, with an average of three shifts occurring per week. Most ED registrars are rostered to a RIC shift once every 3 weeks, and the shifts are now incorporated into the departmental roster. The shifts are rostered from 08.00 hours until at least 14.00 hours; however, the shift might be extended until 17.00 hours at the discretion of the supervising emergency physician.
There are a number of limitations to our study. We performed the study at a single centre, with a small group of registrars, and a motivated group of emergency physicians. Because of our small numbers, we did not have the statistical power to demonstrate a difference of less than two shifts in FACEMs and trainees regarding the optimal number of RIC shifts.
We did not specifically seek information from the registrars about prior experiences of being ‘in charge’ – if the cohort is relatively experienced, then the perceived educational benefits would be less than expected.
Collection of ‘hard’ data regarding the success of the programme was challenging, because of the high rotation of registrars through our department, the lack of validated methods to evaluate the effects of clinical supervision, and the potential for many confounding factors, such as workload, individual motivation and prior experience. We did not attempt to assess specific competencies (such as communication skills) for individual registrars, nor did we collect data on patient flow or ED length of stay during the RIC shifts. Further study could examine the introduction of RIC shifts across multiple EDs in various settings; however, until validated tools are available, it will be difficult to determine whether improved confidence and knowledge in managing the floor translates into better patient care.
Our pilot programme has demonstrated that RIC shifts are a feasible and acceptable educational technique. Registrars gain supervised experience and obtain useful feedback while running the floor of a busy ED alongside an emergency physician. Further study is recommended to determine whether our results can be reproduced in other settings, and to determine whether the educational intervention leads to improved educational or clinical outcomes.
We thank the registrars and emergency physicians who participated in this study.
SC: Study design, data analysis, write-up, final approval before submission. JD: Study design, write-up, final approval before submission.