A national conversation around wellness within our Canadian “emerg” community is not complete without a reflection on culture – the values, beliefs, and practices that make us who we are. As an applied anthropologist and emergency physician, I have spent a fair bit time thinking about the culture of emergency medicine…diving into what really makes us tick. The more I learn, the more proud I am to belong to such a unique and motivated group. The more I dig, the more complexity I uncover in our core values and beliefs and the surer I become that there is much left to learn. The more I observe, the more I appreciate the tensions at the interfaces of our values. Together, we feel and manage the acute conflicts of our organizational culture every day, often without knowing it.
So, why does a discussion of values and their interfaces belong in a week focused on wellness?
Simply put:
When the work that we do does not align with our core values, we feel bad. We all know that feeling. A moment when we notice that a patient we saw 24hrs ago is still in the department waiting to be admitted. Or when we are struggling to arrange a test a patient requires on the timeline that we think it needs to be done. That feeling when we leave a shift heavier, wishing we could have done better.
And, the obvious corollary:
When the work that we do aligns with our core values, we feel good. We have all been part of a well-oiled team that saves a life, or that moment when we coordinate seamless outpatient follow up for a patient with a specialist. That feeling when we leave a shift lighter, knowing that we did good work.
These statements refer to the concept of value congruence: how well the work aligns with our core values. One way to think of how our organisations should approach wellness is to consider how to maximize value congruence1,2,3,4 and minimize value incongruence.
Emergency Medicine: Who Are We?
This might seem like a simple question to answer. Heck, we look after any patient with any problem at any time. We are the calmest people in a crisis. We make order out of chaos. And, we all have a few good stories to tell.
But it turns out that it isn’t quite so straightforward. The values, beliefs, and practices of a group are learned, and taught, and always changing. No single emergency department culture in Canada will be the same but based on my experience there is likely significant overlap in how we see ourselves and our work.
“ We are emergency doctors and nurses and team and so, sort of accepting and dealing with uncertainty is our specialty and we’ve been training for some years to do that.” – Resident
As an anthropologist, I have made a habit of studying groups during times of cultural compression – moments when the values and beliefs of a group bear down with particular intensity. These are moments when culture is both magnified and prospectively shaped. I have studied moments of educational cultural compression like simulation and departmental moments of cultural compression like the COVID-19 pandemic. So far, across these contexts, I have found seven core values particularly relevant to emergency medicine (Figure 1)5. This is by no means a definitive list but rather serves as a starting point for conversations around our collective identity.
Tensions Between Values
When we look at each of these values individually, they all make sense…but where things really start to get interesting is when we think about how and when these values intersect and conflict. Sometimes tension happens because of the inherent contradictions between our core values and sometimes external factors are the cause of the conflict.
When values conflict directly with each other we start to appreciate the inherent contradictions in our values framework. The ability for us to “keep patients and families at the centre of care” sometimes conflicts with our interest and responsibility to “treat and identify life threatening illnesses” and our ability to “balance needs and resources at a system level”. For example, the patient who has a simple runny nose could have a poor individual experience because they had to wait while we resuscitated a critically ill patient. Sometimes we can adapt our systems to fix the inherent conflicts – in this situation, a department may actually have a dedicated “fast-track” doctor to prevent the backlog of minor cases. These inherent conflicts are hard to avoid but worth naming and ameliorating where we can.
Even more pressing are external stressors that directly threaten our core values. For example, for years ED overcrowding has threatened our identity and ability to provide care that aligns with our cultural values. More recently, the pressures associated with COVID-19 are an extreme example of this threat. Our how do we provide care that aligns with our values when resources are overwhelmed?
“You should have a room for everybody, the hallway thing is, you know, I’ve seen it develop over the years and it’s like a bit distressing because it’s not a good thing and I know we’re not the only place that does it, that’s for sure, but how did we get to that?” – ED Nurse
When we start to reframe resource allocation in times of scarcity, or emergency department boarding, or lack of access to outpatient services, or poor infrastructure through the lens of a direct threat to our fundamental identity, we understand more about why these challenges are so problematic, not only for patients, but for the wellbeing and longevity of our emergency medicine community.
Value Congruence and Wellness at the Organization Level
Evidence around individual and organizational wellness is starting to highlight the fundamental importance of value congruence – seeing your work and your values as aligned.1,2,3,4 Organizations espousing shared values and more importantly facilitating employees’ ability to live out those shared values is necessary for individuals and groups to thrive. What does that mean? It means we need to amplify aspects of our work that align with our culture and support identifying and fixing the tensions at value interfaces we find. And they are everywhere…
Some external stressors, like hallway medicine and COVID-19 are “hot topics” – obvious areas of significant tension – at national, provincial, and local levels. Emergency care providers across this country are working tirelessly at leadership tables and especially on shifts each and every day to mitigate the effects of the many big external stressors on our patients and on ourselves. This work feels endless but it is so necessary to both preserving and shaping the culture of emergency medicine.
Skilled leaders understand the significance of value congruence and more importantly how to operationalize this understanding into policies, procedures, and a thriving organic organizational culture that allows people to work in a way that aligns with who they are and how they see their job. The best leaders enable their colleagues to embody the core values of emergency medicine all shift, every shift. In doing so, they empower their workforce to further engage with tensions in a productive way, amplifying the potential.
There are an endless number of smaller areas of tension that can be addressed in our departments by emergency providers at all levels of leadership and practice, the “lower hanging fruit” so to speak. Can the equipment in your resuscitation room be organized better to allow your team to provide more seamless acute care – aligning with the value of “treating and identifying life threatening illnesses”? Maybe you can compile a central list of services affected by the pandemic so each physician isn’t left trying to sort this out on their own for every patient- allowing them to better “balance needs and resources at a systems level.” Perhaps your simulation program should bring together different professions aligning the values of “education is integral” and “a team approach is necessary.” Understanding what values are most important to, or at threat within, your department may help leaders and individuals decide where to focus such efforts.
When we all start to see wellness through the lens of organizational value congruence, it becomes clear that every single decision has a consequential impact. Consideration of that reality should make wellness a part of the very fabric of our departments and communities, rather than simply a “nice to have” optional add on. I like to think that by acknowledging the importance of value congruence in planning initiatives and making decisions, both big ones and small ones, we might preserve a little more of who we are. And, we might even move closer towards the version of ourselves that we most hope to become— that is a charge worth leading.
- Molina, A. Value Congruence. Global Encyclopedia of Public Administration, Public Policy, and Governance.
- Asensio-Martínez Á, Leiter MP, Gascón S, et al. Value congruence, control, sense of community and demands as determinants of burnout syndrome among hospitality workers. Int J Occup Saf Ergo. 2017;25(2):1-32. doi:10.1080/10803548.2017.1367558
- Saito Y, Igarashi A, Noguchi‐Watanabe M, Takai Y, Yamamoto‐Mitani N. Work values and their association with burnout/work engagement among nurses in long‐term care hospitals. J Nurs Manage. 2018;26(4):393-402. doi:10.1111/jonm.12550
- Baugh JJ, Takayesu JK, White BA, Raja AS. Beyond the Maslach burnout inventory: addressing emergency medicine burnout with Maslach’s full theory. J Am Coll Emerg Physicians Open. 2020;1(5):1044-1049. doi:10.1002/emp2.12101
- Purdy E, Alexander C, Caughley M, Bassett S, Brazil V. Identifying and Transmitting the Culture of Emergency Medicine Through Simulation. Aem Educ Train. 2019;3(2):118-128. doi:10.1002/aet2.10325
The world is clearly not a funny place these days. But did you know that humour is actually as good as, or even better, than exercise to help decrease anxiety and depression in medical providers? Even forced laughter has been shown to decrease cortisol levels, increase activity of Natural Killer cells, increase your pain threshold and even cognition. Surprisingly, the absence of in person meetings and social gatherings has provided new ways for humour to bring us together, and it seems like this is more important than ever. 
When I was a kid, I was given a copy of the book Dear Mr. Henshaw by Beverly Cleary.
