Working in Fours: Generational Communication in the Emergency Department

doi:10.21203/rs.3.rs-1606843/v1

Download PDF

Research Article

Working in Fours: Generational Communication in the Emergency Department

https://doi.org/10.21203/rs.3.rs-1606843/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background

This study examined the conflicts between different generations working in the emergency department (ED). We sought to record generational differences involving communication preferences, perceived areas of conflict, work motivations, and attitudes regarding work-life balance.

Methods

We developed a survey to assess the physician perspective on generational conflict in the ED. The survey was distributed to members of the American College of Emergency Physicians (ACEP).

Results

We received 696 completed responses. Men represented 60% of respondents and the largest proportion of respondents were EPs working in community settings (53%); 11% were residents. Generation representation was smallest for Traditionalist (2%) and largest for Gen X (43%). Seventy percent reported observing conflict due to generational communication with the largest frequency being once a week (26%). In the associated open-ended questions, 247 (33%) provided 316 anecdotal descriptions of observed conflict. Responses clustered into seven themes (ordered by frequency): Work Ethic, Treatment Approach, Technology Application, Entitlement, Professionalism, Work Life/Balance, and Communication Style. Comparing Work Ethic responses, 52–70 year olds reported that younger providers are less interested in “accomplishing anything” while 26–34 year olds resented that attitude. Respondents completing the open-ended questions regarding preventing and responding to conflict provided some insight into helpful strategies including actions supportive of clear communication and standardized policies and expectations. Only 5% of respondents reported that they had discussed generational communication in department meetings with the odds of a woman reporting conflict being less than males (p = .01).

Conclusions

Conflicts in the ED can be attributed to how an individual views the values of someone from another generation. Understanding the frequency and areas of generational conflict in the ED can help medical leaders find strategies to mitigate negative workplace interactions.

Generation

communication

emergency department

The present-day emergency medicine (EM) workforce is composed of four generations of physicians, each different in their perspectives, values and attitudes. Each generation shares contemporary political and social events while experiencing similar parenting styles, which results in comparable personal and professional values, work ethic, communication preferences, and leadership styles [1,2]. A generation is defined as “a group of individuals born and living contemporaneously [3].” These groups are popularly known as the Silent Generation/Traditionalists, Baby Boomers, Generation X, and the Millennials or Gen Y [4]. Gen Z is the newest generation entering the workforce [5]. Generational differences are known to impact the healthcare environment by creating tension and conflict when values differ [6,7].

Generations Overview: Who Are We?

The four generations are generally classified by birth year and defined by the significant historic events that took place during their lifetime [2,4,6,7]. The Silent Generation (also known as Traditionalists) includes those born between 1925 and 1945 who were greatly influenced by the Great Depression and post-WWII recovery. They are often described as loyal, hierarchal, patriotic and altruistic while placing a high value on work ethic, respecting authority, and remaining loyal to an employer [2,4]. Baby Boomers were born between 1945 to 1964 and were shaped by an era of post-war prosperity, the Civil Rights Movement, women’s movements, and the Vietnam War. They tend to be workaholics who sacrifice personal life for professional advancement, but differ from the Silent Generation by exhibiting rebellious attitudes toward authority [4,8]. Generation X refers to those born between 1964 and 1980 who were influenced by events like the Cold War, AIDS epidemic and rising divorce rates. “Gen Xers” were the first of the “latchkey kids” and therefore are independent, question authority, and are more casual in their approach to work and life [4,6]. Millennials (also known as Generation Y) were born between 1980 and 2000 and experienced the tragedy of 9/11 with ongoing threats of terrorism, the Iraq and Afghanistan wars, and the globalization of business and economics. They were raised in child-centered families while always having technology available to them. They are more globally aware, team-oriented, and collaborative [1,2,4,6]. Gen Z is the newest generation, but they did not join the medical workforce until after our data was collected [4].

There are about 938,980 active physicians in the United States, with emergency physicians (EPs) numbering about 45,000. Of EPs, 35% are age 55 or older (Traditionalists and Baby Boomers) and 65% are younger than 55. There are about 8,000 EM residents and fellows [9].

There is a significant amount of research addressing generational diversity and communication in healthcare, however little research has been conducted categorizing the specific tensions attributed to generational communication conflict in the Emergency Department (ED). These generational characteristics differ enough to cause misunderstandings that in turn can interfere with patient care goals and department administrative functioning [7]. The importance of reducing workplace conflicts in the ED cannot be understated; teamwork is essential to patient care [10]. Understanding and respecting the generational values can mitigate these conflicts and frustrations and is essential for collaboration and teamwork [6,11].

The goal of this study is to better characterize generational workplace conflict in the ED. We hypothesize there are generational differences involving communication preferences, perceived areas of conflict, and attitudes regarding work-life balance that contribute to workplace conflict. To effectively lead in the ED, physicians should understand generational stereotypes to help guide interpersonal interactions across generations [12].

Aim, Design and Setting

This was a cross sectional survey study approved by the Loma Linda University Institutional Review Board and the American College of Emergency Physicians (ACEP) Board. The project was supported by a section grant awarded by ACEP to the American Association of Women Emergency Physicians (AAWEP).

Study Setting and Population

We distributed a survey to ACEP members. The survey instrument was drafted by the authors, shared with a convenience sample of AAWEP members, and modified per their feedback. It was then piloted to a separate sample of 8 EPs and refined again. The final survey instrument was produced in electronic (Qualtrics Inc., Provo, UT) format.

Study Protocol

The ACEP central office distributed the electronic survey link on behalf of the authors in late 2016, followed by three reminders over a 10 week period. The survey took an average of sixteen minutes to complete and was anonymous.

Key Outcome Measures

Our primary outcome measure was the frequency of observations attributed to generational conflict as defined by respondents. Secondary outcomes were the type of conflict, observations of how the conflict was resolved, suggestions for preventing identified issues, and frequency this issue was discussed in department meetings.

Data analysis

We descriptively report all results using STATA 15.1 (StataCorp College Station, TX). Open-ended questions regarding conflict anecdotes were coded by two independent coders. Response coding was refined through an iterative design process comparing coding agreement to achieve consistent category assignment [13].

Subject Characteristics

Table 1

Respondent Characteristics (n/%)
	Generations
	Millennial	Gen X	Baby Boomer	Traditionalist	Total
Gender¹
Male	73 (11)	154 (23)	159 (24)	13 (2)	399 (60)
Female	68 (10)	133 (20)	62 (9)	*	264 (40)
Total	141 (21)	287 (43)	221 (33)	14 (2)	663
Role²
Academic EP	38 (6)	94 (14)	52 (8)	*	184 (26)
Community EP	37 (5)	179 (26)	150 (22)	6 (1)	372 (53)
Residents	65 (9)	14 (2)	*	*	79 (11)
Other	7 (1)	11 (2)	23 (4)	*	44 (6)
Total	147 (21)	299 (43)	235 (34)	15 (2)	696
Note: Percentages may not add up to 100 because of rounding, *notes cell frequency < 5.
¹Pearson chi2(5) = 28.26, p < .001; ²Pearson chi2(15) = 332.30, p < .001

Main Results

When asked about conflict, 70% reported observing conflict due to generational communication. The largest frequency was once a week (26%), followed by daily (20%) and 2-3x/week (17%). Responses by gender differed significantly overall, but not by generation or role. Table 2 details these results.

Table 2

Conflict Observation (n/%)
	Observed Conflict Due to Generational Communication
	Yes	No	Total
Generation¹
Millennial	102 (71)	45 (29)	147
Gen X	212 (71)	87 (29)	299
Baby Boomer	160 (68)	74 (32)	234
Traditionalist	9 (56)	7 (44)	16
Total	483 (70)	213 (31)	696
Gender²
Male	259 (65)	138 (45)	397
Female	201 (76)	63 (24)	264
Total	460 (70)	201 (30)
Role³
Academic EP	136 (74)	47 (26)	183
Community EP	254 (68)	118 (32)	372
Residents	51 (41)	28 (59)	125
Other	40 (67)	20 (33)	60
Total	481 (70)	213 (31)
Note: Percentages may not add up to 100 because of rounding.
¹Pearson chi2(3) = 1.74, p = .63; ²Pearson chi2(1) = 8.90, p < .01; ³ Pearson chi2(3) = 5.87, p = .32

In the associated open-ended questions, 247 (33%) provided 316 anecdotal descriptions of observed conflict. Responses clustered into seven themes (ordered by frequency): Work Ethic, Treatment Approach, Technology Application, Entitlement, Professionalism, Work Life/Balance, and Communication Style. Figure 1. For example, comparing Work Ethic responses, Baby Boomers reported that younger providers are less interested in “accomplishing anything” while Millennials resented that attitude. Table 3 defines each theme, supported by exemplary quotes contrasting the least and most common category reported by generation group.

Table 3

Conflict Themes Definition and Illustrations
Category Definition	Exemplary Quotes (Frequency by Generation)
	Least Common	Most Common
Work Ethic ● Valuing self over patient ● Less patient interaction and dependence on social media to communicate	Millennial: I resent the attitude that residents today are lazy. Older physicians have burned out and don't do the right thing and take care of patients.	Baby Boomer: There is a striking difference in apparent work ethic, with many younger workers (nurses more than docs, but both) seeming to be much less interested in actually accomplishing anything and more interested in punching the time clock as compared to older folks. Does my bias show? It's "not my job" vs "I'll make sure it gets taken care of..."
Treatment Approach ● Authoritarian v. patient centered ● Sticking to tradition with lack of evidence	Gen X: People in the generation right behind mine tend to question everything because they want to understand, but people in my generation and especially the generation above me tend to want their orders followed without question. I have seen this on numerous occasions where an older person asks a younger person to do something and gets upset when they get a million questions.	Millennial: Older attendings not being receptive to current literature and doing things based on anecdotal evidence. When opinions vary in subjective scenarios and the older generation demands that one way be done because "that's how it is always done" even with recent evidence to suggest otherwise. There are also times when teamwork and hierarchy cause conflict in stressful situations.
Technology Application ● Underuse or overdependence on technology for patient care and communication ● Perception that technology use is replacing patient-centered care	Baby Boomer: I have less computer savvy than my younger partners, and thus have more difficulty learning ultrasound, using simulators, learning from "podcasts," etc. Different modalities of communication and information gathering - social media vs. email I ask another provider "do you remember the dose of ....?" and they pick up a smart phone and google it.	Millennial: Traditionalists can't give up printing lab values out when they are on the EMR. A senior staff member occasionally submits hand-written requests for our online scheduling program. Older ED physicians needing help navigating the EMR/system: putting in the correct orders, diagnoses, etc.
Entitlement ● Expecting individual accommodations ● Perception that the younger generations want rewards before they have “put in their time”	GenX: Entitlement among residents and/or junior faculty members. Residents/junior faculty members craving direct feedback for improvement while older faculty feel uncomfortable providing such feedback.	Traditionalist: Younger physicians seem to want instant rewards rather than working their way up through a system. Trainees wanting the program to adapt to them, rather than their adapting to a new role.
Professionalism ● Patient perception ● Problems with credibility ● Perceptions of respect	Millennial: The lack of professionalism in terms of timeliness, respect for authority. Mostly related to accepted dress in ED.	Baby Boomer: Residents nowadays need constant feedback. Medical students are not as respectful as we used to have to be - referring to attendings by first name. Older male colleagues will call female residents "blondie." Younger physicians being poor at communicating with older patients as well as the reverse. The older team member did not feel that the younger team member was professional in interacting with patients. The younger team member did not share the same social values held by the older team member. The younger was much more casual when interacting with older patients. The older team member felt this was too casual, calling patients by first names, not addressing them with Ma'am or Sir. I think it is a generational difference.
Work/Life Balance ● Problems with staffing coverage ● Burnout because of desire to balance work/family life	Millennial: Told by my female program director that taking more than 6 weeks maternity leave was selfish and unprofessional. She followed by saying that the Hippocratic oath never mentioned family, and that I need to get used to that fact that I'm a doctor now, so my career comes before everything, including my family.	Traditionalist: Younger emergency physicians have bought into the philosophy that lifestyle (i.e. privilege) trumps taking care of patients (i.e. responsibility). They have chosen this specialty not for the work but for the time off to indulge their pleasure. They have forgotten that recreation, by definition, is to re-create one to return to their essential task-work. Intermediate plans include getting off of night shifts by their 40's, retire by their 50's.
Communication Style ● Perception that critical feedback is equivalent to anger ● Use of language perceived to be offensive	Baby Boomer: Direct communication is perceived as anger. Young RN gets told to do a job. She/He perceives the tone of voice to be very aggressive and files a bullying charge. Young residents do not take negative feedback well. They look only for positive reinforcement. They also text more often rather than calling by phone to change schedules..	Millennial: Residents not perceiving faculty participation on conference attendance.

Most respondents reported communication issues

There is a difference in work ethic where my generation believes in work above all else (often to the detriment), and younger physicians see work as only a part of their life. The ease with which younger physicians adapt to electronics is certainly a difference. I think each group brings value to the practice of Emergency Medicine. The trick is recognizing and appreciating the different points of view. (Quote from a Traditionalist)

Our study revealed that the majority of respondents reported generational communication issues at least once per week with 20% reporting daily issues. Academic EPs reported more conflict than those that work in community settings. Qualitative analysis of the coded responses revealed clear differences in generational perspectives on conflict and women observed more conflict than men. Each generational cohort brings unique skills, perspectives and demands that must be acknowledged to maximize communication and productivity in the ED [14]. ED physician leaders need to maintain and strengthen team structures while promoting excellent teamwork and collaborative practice [15].

Potential Conflict Areas

There are lots of little things that come up during the day - one of the most common is an older patient or a patient’s older family member making some remark about the resident or even the attending being "too young to be a doctor" or "too pretty." Often there isn’t much more to it than that, at least on the surface, but I'm sure those patients would be more satisfied and their press ganeys would be better if they had older male doctors at their bedside.(Quote from a Millennial)

Understanding the areas of potential conflict is critical for ED functioning [16]. We identified seven themes: Work Ethic, Treatment Approach, Technology Application, Entitlement, Professionalism, Work Life/Balance, and Communication Style. Our survey revealed the highest numbers of conflicts were regarding Work Ethic and Treatment Approach. This is consistent with literature explaining that generational values differ by their attitude towards work. Baby Boomers are often described as “living to work”, while Gen Xers “work to live,” and Millennials “work while living [4].” Generation X and Millennials may be perceived as less committed to medicine because, unlike the two previous generations, they tend to favor a work/life balance as opposed to more professional responsibilities [17]. Our respondents agree; when comparing Work Ethic responses, Baby Boomers reported that younger physicians are less interested in “accomplishing anything,” while Millennials resented that attitude. Treatment Approach conflicts centered around “older specialists tend to hold on to outdated beliefs” and perceived resistance to learning new practices. Of our seven conflict themes, conflict in the area of Work/Life balance was the second to last, which was unexpected given previous research done on areas of generational conflict in medicine [8].

Considerations for Emergency Department Directors and Leaders

There is a difference in priorities, especially in terms of dedication to the workplace. Older generations placing a priority on work and younger generations placing a priority on self. (Quote from a Gen X)

The role of the ED director is to recognize and solve problems, however reporting of generational conflict is not common. Our study showed that while most people attribute conflict to generational differences, the subject is not discussed in department meetings. Directors should also recognize the potential for generational differences to vary by gender. Our data reveals that women EPs were more likely to report generational conflict than men. Recognition of the common presence of generational conflict in the ED can lead to department conflict mitigation strategies focusing on clear communication with standardized policies and procedures.

Better communication and understanding needs to happen for the ED to function, rather than allowing negative statements or generational stereotypes to fester [18]. Incentive and promotion structure could be optimized with explicit workplace expectations, avoiding vague principles or assumptions [14].

Strategies to Mitigate Generational Issues in the ED

Issue: The music being played in the physician charting area that is not enjoyable to many older physicians who are trying to chart electronically or dictate.(Quote from a Baby Boomer)

I am on the tech end of Gen X and wish to work on projects through asynchronous communication tools, such as project management software, but some of the Boomers are slow or reluctant to adopt this sort of workflow, preferring 7am meetings instead.(Quote from a Gen X)

Generational differences and communication research have been performed among nurses [11,19] and medical specialties including surgery [20], pediatrics [16], Ob-Gyn [18], anesthesia [7], and neurologists [21], however we do not know of another paper describing generational communication conflict in the ED setting. It is critical that the department director create a work environment that embraces generational differences to maximize effectiveness [8]. Respondents recognized the pitfalls of generational communication in the ED because “clinical urgency/emergency forces potential for misunderstandings.” Recommendations for improved policy, training, and communication practices are outlined in Table 4.

Concrete solutions for generational conflict in the ED are an area for further research. A toolkit “Working with Generations in the Emergency Department” was developed from this research to stimulate discussion about the assets and challenges of working with multiple generations and is freely available [22]. Curriculum is needed to assist these efforts [23].

Limitations and Further Investigation

Our survey is self-reported, however there may be bias related to people venting negative experiences which underplays the value of the generational workforce. The use of cross-sectional surveys fails to capture the influence of the aging process. Our study may have not adequately accounted for differences due to cultural norms, such as avoiding eye contact to communicate respect, and these issues should be explored in any team effort to address generational conflict. Generation representation in our survey was smallest for Traditionalist, thus their voice may not be fully understood. Further investigation of what ED workplace characteristics are important to each generation could provide useful information for administrators tasked with recruitment, retention and scheduling.

Generational values and characteristics differ enough to cause misunderstandings that in turn can interfere with patient care goals and administrative functioning of a department. Understanding and respecting the values of four generations working side by side in the ED can mitigate conflicts and frustrations and is essential for collaboration and teamwork. It is critical that department directors create a work environment that embraces generational differences to maximize effectiveness. Concrete solutions for generational conflict in the ED are an area for further research.

Ethics approval and Consent to Participate: This research study was reviewed and approved by the Loma Linda University Institutional Review Board (IRB #5150374). The study was approved for a waiver of signed consent. Participants were informed that by completing the anonymous survey they were providing implied consent. I certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests: MG, ER, TP, BK, SL, CD, CW and ELW report no conflict of interest.

Funding: This project was supported by a section grant to the American Association of Women Emergency Physicians from the American College of Emergency Physicians.

Author contributions: MG, ER, TP, and ELW developed the study concept and design. MG, ER, TP and ELW each participated in the acquisition of data, analysis and interpretation of the data. MG, ER, BK, SL, CD, CW and ELW drafted and critically revised the manuscript for important intellectual content. ER helped with statistical expertise. ER and ELW acquired the funding. All authors read and approved the final manuscript.

Acknowledgements: Not applicable

Howell LP, Joad JP, Callahan E, Servis G, Bonham AC. Generational forecasting in academic medicine: a unique method of planning for success in the next two decades. Acad Med. 2009;84(8):985-93.
Mohr NM, Moreno-Walton L, Mills AM, Brunett PH, Promes SB; Society for Academic Emergency Medicine Aging and Generational Issues in Academic Emergency Medicine Task Force. Generational influences in academic emergency medicine: teaching and learning, mentoring, and technology (part I). Acad Emerg Med. 2011;18(2):190-9.
Moreno-Walton L, Brunett P, Akhtar S, DeBlieux PM. Teaching across the generation gap: a consensus from the Council of Emergency Medicine Residency Directors 2009 academic assembly. Acad Emerg Med. 2009;16 Suppl 2:S19-24.
Boysen PG 2nd, Daste L, Northern T. Multigenerational Challenges and the Future of Graduate Medical Education. Ochsner J. 2016;16(1):101-107.
Chicca J, Shellenbarger T. Connecting with generation Z: approaches in nursing education. Teach Learn Nursing. 2018;13(3):180-184.
Olde BM, Farrell SE, Takayesu JK. Interprofessional communication in the emergency department: residents' perceptions and implications for medical education. Int J Med Educ. 2018 Oct; 25(9):262-270.
Shangraw RE, Whitten CW. Managing intergenerational differences in academic anesthesiology. Curr Opin Anaesthesiol. 2007;20(6):558-63.
Lim A, Epperly T. Generation gap: effectively leading physicians of all ages. Fam Pract Manag. 2013;20(3):29-34.
Association of American Medical Colleges. Physician Specialty Data Report. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/active-physicians-age-and-specialty-2019 [Accessed 6 August 2021]
Im D, Aaronson E. Best practices in patient safety and communication. Emerg Med Clinics North America. 2020;38(3):693-703.
Bell JA. Five generations in the nursing workforce: implications for nursing professional development. J Nurses Prof Dev. 2013;29(4):205-210.
Tolbize, A. Generational differences in the workplace. Research and Training Center on Community Living.2008. Available at: https://rtc.umn.edu/docs/2_18_Gen_diff_workplace.pdf [Accessed 9 August 2021]
Crabtree BF, Miller WL. Doing qualitative research. Thousand Oaks, CA: Sage Publications; 2000.
Moriarity AK, Brown ML, Schultz LR. We have much in common: the similar inter-generational work preferences and career satisfaction among practicing radiologists. J Am Coll Radiol. 2014;11:362-368.
Lateef F. Grace under pressure: leadership in emergency medicine. J Emerg Trauma Shock. 2018;11(2):73-79.
Spector ND, Cull W, Daniels SR, Gilhooly J, Hall J, Horn I, Marshall SG, Schumacher DJ, Sectish TC, Stanton BF. Gender and generational influences on the pediatric workforce and practice. Pediatrics. 2014;133(6):1112-1121.
Jovic E, Wallace JE, Lemaire J. The generation and gender shifts in medicine: an exploratory survey of internal medicine physicians. BMC Health Serv Res. 2006;6:55.
Phelan S. Generational issues in the Ob-Gyn workplace: “Marcus Welby, Md,” versus “Scrubs”. Obstet Gynecol. 2010;116(3):568-9.
Christensen SS, Wilson BL, Edelman LS. Can I relate? A review and guide for nurse managers in leading generations. J Nurs Manag. 2018 Sep;26(6):689-695.
Vanderveen K, Bold RJ. Effect of generational composition on the surgical workforce. Arch Surg. 2008;143(3):224-226.
Elkind MS. Teaching the next generation of neurologists. Neurology. 2009;72(7):657-663.
Walters E, Reibling E, Leung N, Guptill M, Wire J, Clem K. Working with generations in emergency medicine toolkit. 2017. American College of Emerg Med. Available at https://www.acep.org/globalassets/uploads/uploaded-files/acep/membership/sections-of-membership/grant/working-in-fours-toolkit-final.pdf [Accessed 9 August 2021]
Murakami M, Matoba K, Hyodoh H, Takahashi M. Generation gaps in medical education: An exploratory qualitative study. J Pak Med Assoc. 2021 May;71(5):1476-1478.

No competing interests reported.

Download PDF

Version 1

posted

You are reading this latest preprint version

Working in Fours: Generational Communication in the Emergency Department

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Generations Overview: Who Are We?

Methods

Aim, Design and Setting

Study Setting and Population

Study Protocol

Key Outcome Measures

Data analysis

Results

Subject Characteristics

Main Results

Suggested Solutions

Discussion

Most respondents reported communication issues

Potential Conflict Areas

Considerations for Emergency Department Directors and Leaders

Strategies to Mitigate Generational Issues in the ED

Limitations and Further Investigation

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1