Working in fours: generational communication in the emergency department

Background This study examined the conflicts between different generations working in US emergency departments (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, a professional organization comprising emergency medicine physicians in the USA. Results We received 696 completed responses. Men represented 60% of respondents and the largest proportion of respondents were emergency physicians 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). Conclusion Conflicts in the ED in the USA 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. Supplementary Information The online version contains supplementary material available at 10.1186/s12245-023-00536-7.


Introduction
The present-day emergency medicine (EM) workforce in the USA is composed of four generations of physicians, each different in their perspectives, values, and attitudes.A generation is defined as "a group of individuals born and living contemporaneously" with geography significantly influencing the formation of generational culture, beliefs, and behavior [1].In the USA, the generations shared 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 [2,3].Western or US generational models cannot be applied to the global EM workforce as each country's unique social, political, and economic events shaped today's adults.This study examined the conflicts between different generations working in US emergency departments [4].The US generations included in this study are popularly known as the Silent Generation/Traditionalists, Baby Boomers, Generation X, and the Millennials or Gen Y [5].Gen Z is the newest generation entering the workforce [6].Generational differences are known to impact the healthcare environment in the US by creating tension and conflict when values differ [7,8].

US generations overview: who are they?
The four generations are generally classified by birth year and defined by the significant historic events that took place during their lifetime [2,5,7,8].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 [5,9].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 often described as independent, questioning authority, and more casual in their approach to work and life [5,7].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 described as more globally aware, teamoriented, and collaborative.Millennials are also described as having poor work ethic, flexibility fixation, low job loyalty, and difficulties with face-to-face communication [1,2,5,7].Gen Z is the newest generation, but they did not join the medical workforce until after our data was collected [6].
There are about 938,980 active physicians in the USA, 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 [10].
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 [8].The importance of reducing workplace conflicts in the ED cannot be understated; teamwork is essential to patient care [11].Understanding and respecting the generational values can mitigate these conflicts and frustrations and is essential for collaboration and teamwork [7,12].
The goal of this study is to better characterize generational workplace conflict in the US ED.We believe 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 differences to help guide interpersonal interactions across generations [13].

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.ACEP is a professional organization comprising emergency medicine physicians in the US.This organization was founded in 1968 by a group of 8 physicians dedicated to improving the quality of emergency care.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 35,658 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.The survey is attached as a supplementary file.

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, who are both authors on this manuscript.Response coding was refined through an iterative design process comparing coding agreement to achieve consistent category assignment [14].Codes were routinely reevaluated to ensure consistency and to identify codes needing clarification.After all comments were analyzed, the authors met four times to summarize codes into major themes and identify exemplary quotes relevant to each theme, and any discrepancies were resolved by discussion.

Subject characteristics
We received 696 completed responses.The response rate for this study was 2%.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%).Our survey did not include race or nationality demographic data but focused on the age and sex of respondents See Table 1.

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 2-3 × /week (17%).Responses by gender differed significantly overall, but not by generation or role.Table 2 details these results.

Suggested solutions
Respondents completing the open-ended questions regarding preventing and responding to conflict provided some insight into helpful strategies.These responses are listed in Table 4.Most responses reflected actions supportive of clear communication and standardized policies and expectations.Some comments expressed dismay at not knowing what to do or lamented that the ED environment "forces potential for misunderstandings" that are difficult to resolve thus reinforcing the need for this study.

Table 1 Respondent characteristics (n/%)
Percentages may not add up to 100 because of rounding, *notes cell frequency < 5 1 Pearson chi 2 (5) = 28.26,p < .001; 2  Only 5% of respondents reported that they had discussed generational communication in department meetings.

Discussion
Our study revealed that most respondents reported generational conflicts regardless of setting type (US academic or community ED).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 [15].ED physician leaders need to maintain and strengthen team structures while promoting excellent teamwork and collaborative practice [16].

Potential conflict areas
Understanding the areas of potential conflict is critical for ED functioning [17].We identified seven themes: Work Ethic, Treatment Approach, Technology Application, Entitlement, Professionalism, Work Life-Balance, and Communication Style.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." [5].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 [18].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 Work-Life balance was unexpectedly rare given previous research done on areas of generational conflict in medicine [9].

Considerations for emergency department directors and leaders
The role of the ED director is to recognize and solve problems, while considering how hierarchical positions and gender roles may intertwine with conflicts displayed as generational ones.The US ED leadership positions are mostly held by Baby Boomers, while Gen Xers are relegated to midlevel positions [2].Understanding generational preferences and frames of reference is essential for collaboration and teamwork in the ED [12].In the US ED setting, 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 [19].Incentive and promotion structure could be optimized with explicit workplace expectations, avoiding vague principles or assumptions [15].[12,20] and medical specialties including surgery [21], pediatrics [17], Ob-Gyn [19], anesthesia [8], and neurologists [22]; however, we do not know of another paper describing generational communication conflict in the US ED setting.It is critical that the department director create a work environment that embraces generational differences to maximize effectiveness [9].Respondents recognized the pitfalls of  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 A medical student wanted time off that would not work with the schedule.She did not seem to understand that she was not special and schedule could not be bent to fit her specific requests I see that some newer people do not hesitate to switch jobs or leave a situation that doesn't meet every single one of their expectations Lack of understanding that sometimes you have to just "suck it up" Professionalism Millennial:

Generational differences and communication research have been performed among nurses
Baby Boomer: • Patient perception • Problems with credibility • Perceptions of respect 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." The lack of professionalism in terms of timeliness, respect for authority Mostly related to accepted dress in ED Medical students are not as respectful as we used to have to bereferring 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 Work-Life Balance Millennial: Traditionalist: • Conflict related to staffing the ED • Burnout because of desire to balance work/family life 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 There are really unspoken conflicts around scheduling, mainly night shifts Younger physicians, often parents, place high value on balance and family time.This is often misinterpreted as laziness or lack of investment in their profession, with negative consequences Younger emergency physicians have chosen this specialty not for the work but for the time off to indulge their pleasure.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 online [23].Curriculum is needed to assist these efforts [24].

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.The survey response rate was low (2%), potentially making the sample less representative with sampling bias.Generation representation in our survey was smallest for Traditionalist, thus their voice may not be fully understood.We did not include demographic data related to race and nationality but focused on age and sex of respondents.Further investigation of what ED workplace characteristics are important to each generation, including race and nationality, could provide useful information for administrators tasked with recruitment, retention, and scheduling.

Conclusion
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.

Table 3
Conflict themes definition and illustrations