BRAVE: A Point of Care Adaptive Leadership Approach to Providing Patient-Centric Care in the Emergency Department.

The practice of emergency medicine has reached its cross roads. Emergency physicians (EPs) are managing many more time-dependent conditions, initiating complex treatments in the emergency department (ED), handling ethical and end of life care discussions upfront, and even performing procedures which used to be done only in critical care settings, in the resuscitation room. EPs manage a wide spectrum of patients, 24 h a day, which reflects the community and society they practice in. Besides the medical and "technical" issues to handle, they have to learn how to resolve confounding elements which their patients can present with. These may include social, financial, cultural, ethical, relationship, and even employment matters. EPs cannot overlook these, in order to provide holistic care. More and more emphasis is also now given to the social determinants of health. We, from the emergency medicine fraternity, are proposing a unique "BRAVE model," as a mnemonic to assist in the provision of point of care, adaptive leadership at the bedside in the ED. This represents another useful tool for use in the current climate of the ED, where patients have higher expectations, need more patient-centric resolution and handling of their issues, looming against the background of a more complex society and world. Copyright:

INTRODUCTION

The provision of care in the emergency department (ED) is fast-paced and requires a lot of fast-thinking strategies. The work is hectic, while the workload is heavy. Emergency physicians (EP) provide consultation for a wide spectrum of emergencies, going through patient after patient, getting a good and succinct history, performing the most accurate physical examination as well as ordering the appropriate sets of investigations, bearing in mind to be cost-efficient at all times.[12] These steps in clinical reasoning are crucial and is strengthened, many times over, through every patient encounter.[345] Being busy does not mean being less humane or brushing aside all the humanistic aspects of interaction and socialization. Every patient is an individual, with character, values, and principles, as well as a set of relatives/family that represent an extension of their social networks into the community. With their training and mental model, EPs do thrive in a Volatile, Uncertain, Complex, Ambiguous, and Hyperconnected (VUCAH) environment. They rise readily to the technical challenges. This, however, must be balanced with the eye for adaptive leadership and management. For adaptive problems, there may not be a set of established processes or procedures to address them. There may not be trained “experts” to deal with the spectrum of problems at hand. In short, there are no technical fixes. This is where we are proposing the EP can serve as an adaptive leader to help define the problems and issues and subsequently mobilize the relevant personnel to come up with the solutions and answers.[267]

EMERGENCY DEPARTMENT VERSION OF VOLATILE, UNCERTAIN, COMPLEX, AMBIGUOUS, AND HYPERCONNECTED CHALLENGES

In managing an “emergency,” getting the diagnosis right, with the appropriate patient response to treatment, is not the only goal. There is of course the patient, who is at the center of it all, together with their associated behavior, expectations, understanding of their medical problems, cultural background, financial capabilities, as well as their social circumstances, to be considered.[891011] Therein lies the technical versus the adaptive problems in approaching every person in an optimal patient-centric manner. With technical problems, usually a satisfactory, predetermined response is available. These problems tend to be more “mechanical.” Eps, in general, are well trained at managing the technical issues or the range of medical problems they encounter daily. They perform resuscitations and procedures, manage complex and multifaceted medical conditions, and order a wide range of investigations as well as medications to suit each patient's needs.[6781012] The ED represents a complex health-care environment. If in the economic context we refer to the VUCAH challenges, the ED too has its version of VUCAH [Table 1].[1131415]

Table 1

Volatile, uncertain, complex, ambiguous, hyper-connected challenges including emergency department version of volatile, uncertain, complex, ambiguous, hyper-connected

VUCAH challenge	ED version
Volatility	Ever-changing, extremely dynamic, with frequent “ups and downs”
Uncertainty	Unpredictability, there may be some good days and some busy days
Complexity	Various workflow, pathways as well as work processes in the ED are complicated and multi-faceted. There are also algorithms for the management of the spectrum of conditions/diagnoses, which can present in various permutations and combinations
Ambiguity	Refers to a situation which is unclear, nebulous and may need further work-up or follow-up for better clarity and definition. Thus, the need for ongoing surveillance. EPs need to have a high index of suspicion in all circumstances, remain astute and vigilant A good example is the current COVID-19 pandemic where EDs have to adapt quickly, sometimes with limited information available
Hyper-connectivity	Well networked and integrated, both upstream and downstream. For example, the ED is linked to the prehospital environment through interaction with paramedics from the EMS as well as the inpatient hospital environment through the staff from the various departments and specialties.

VUCAH: Volatile, uncertain, complex, ambiguous, hyper-connected, ED: Emergency department, EMS: Emergency medical services

Technical and adaptive leadership challenges

In the course of performing the range of technical tasks, EPs interact and build rapport with the patients and their families. The EPs will get to understand a little pertaining to their patients’ behavior, attitude, and expectations.[10] The latter may be seen as the “softer elements” or the “soft sciences” when it comes to managing the ED patients, but these do complement the technical tasks and decisions made. They contribute toward the holistic management of the ED patient. To be really patient-centric, these are indeed important considerations, which are often overlooked or deemphasized as they are not perceived to be as high priority or straightforward as the technical aspects of patient care. EPs need to actively showcase their humanistic skills and demonstrate empathy as they elicit history and information on the patient's background and context, consider the next steps, and plan how to negotiate agreement with the patient and family members. These are known as the adaptive issues and challenges.[10121617]

Managing technical and adaptive leadership challenges

Technical problems are usually easy to identify. Once diagnosed, there may be algorithms and pathways to follow for treatment and management. Professionals and specialists in certain disciplines are able to appreciate, manage these conditions, and implement solutions. In the ED, patients are, in general, receptive toward these technical solutions. For example, if a patient comes in with poorly controlled blood pressure, he will get a specific set of investigations to assess the impact on end-organs and be prescribed the appropriate antihypertensive medications.[16181920]

Adaptive challenges, on the other hand, are less obvious and, thus, not so easy to identify. EPs must be able to anticipate or preempt some of these. It is likely to be linked to experience, awareness, and the ability to make a conscious effort in identifying and sorting out some of these issues.[171921] Management of these adaptive challenges may pose barriers such as the need for behavioral changes, mindset management, handing of issues that affect relationships, and have upstream and downstream impact. These actions and interventions may also be more time-consuming and may involve “going the extra mile.” An example would be, attempting to change a negative behavior in a patient who presents with frequent giddiness and has not been taking his antihypertensive medication. Counseling on compliance, checking on affordability to pay for the medications, understanding his social background and occupation, the level of family support, as well as other factors are important. These are all definitely not as simple as writing a prescription. It requires patience, time, effort, and empathy on the part of the EPs.[18192122]

Tackling adaptive challenges involves the following:[716171923]

Recognizing that a problem exists or can potentially exist and thus, the quest to figure out a solution or potential resolution

In wanting to attain resolution for the adaptive issues, it is crucial to realize that this may involve behavior and mindset change on the part of the patient/family members

This process takes time and has trade-offs that the patients/family have to make

In handling these, EPs have to exercise both their technical and adaptive leadership capabilities, at the bedside of the ED patient vis-a-vis, point-of-care (POC) leadership.

Point of care adaptive leadership

Adaptive leadership is often referred to in the corporate context. It has thus far been about dealing with adaptive problems that arise in a company or organizations. As such, many may envision it to be practiced and applied only at the highest echelons of leadership and organizations. Other forms of leadership too are often misperceived as applicable only to those at the highest levels and hierarchy of the health-care organization. Often overlooked are the various acts, which constitutes leadership, taking place at the frontline and on the clinical floors by individual care providers or staff, who render close and personalized care to patients.[1224] Similarly, in the ED, the one-on-one trusting and enabling relationships between EPs and patients are the building blocks of leadership in the department and organization. At the first point of contact, ED patients are in pain, concerned, excited, upset, or anxious about their symptoms. They have a certain level of expectations conjured in their minds. The EPs must be able to address these concerns and symptoms, explain in laypersons’ terms without medical jargon, what the diagnosis is. The conversation must continue to clarify procedures the patient may need, medications to be administered as well as investigations. The risks must not be left out either. The knack of being able to carry these out adequately and comprehensively while making the patient feel reassured and confident in his EP, is important.[10]

Nonverbal communications

There is much to be interpreted by the patients when it comes to nonverbal communications. Being able to take charge, be in control and at the same time, show empathy and humanistic values is crucial in the work of an EP. Communicating with hope is important, especially at the frontline in the ED as patients are still fragile in terms of their emotions, experience of pain, confusion, and worries in facing an acute crisis.[122526] EPs have to ensure there is no false hope, but instead, sharing with empathetic honesty. Hope can stimulate recovery, compliance, and even get greater buy-in from patients. The ability to nurture hope can be the starting point for more in-depth discussions, once patients perceive the genuine approach by the EPs. They will then feel comforted to share the smallest details which can help EPs with their adaptive leadership approach to sorting out their patients’ issues. In such conversations, patients will feel valued, safe, and cared for, even in the busy environment of the ED. In line with managing their patients and keeping them positively inspired, EPs must not forget to keep themselves inspired as well, as this is important in sustaining their adaptive leadership approach.[212324262728]

Planning and making decisions

In the ED, it is not just about doing, but also involves observation and getting a “helicopter view” of how things are progressing with the patient. Taking a step back to observe the patient and proceed in a compassionate and supportive manner may be necessary. These inputs are very useful in planning the forward interaction. Intentional listening with an open mindset is helpful as it inculcates patience, nonjudgmental approach and strengthens the rapport between the EP and the patient. All these contribute toward building trust with the patient. In short, it represents the POC adaptive leadership that each EP can demonstrate and contribute toward patient-centric care. This type of adaptive leadership should not be underestimated as these staff are ‘ambassadors’ at the ‘front door’ of the health-care institution. The work of the EP at the point of care involves the same principles that guide adaptive leadership:[29]

Anticipation: Of patients’ needs and options

Articulations: Building support and understanding for patients’ circumstances

Adaptation: Customization and adjustment of response

Accountability: Ownership and transparency in decision situations

Awareness: Understanding the ‘big picture’ view and progress.

DEVELOPING A MODEL APPROACH

With the right mindset and “model of approach” they can tend to patients’ issues, both technical and adaptive. They can have the capacity to change behavior, inculcate values, and enhance collaboration with patients and the public.[7121718] After all, EM is not above society, but reflects society.[29] It is important to realize that even with this adaptive leadership model approach, it does not mean EPs can solve every single patient issue or problem. Some of these are complex and multifaceted and need time and repeated analysis. What it does is, open up options for exploration and for EPs to discuss potential solutions or action with the patient. This adaptive, big picture approach is also relevant from the patient's perspectives. It would harness factors such as the patient's health beliefs, motivation about their health and mental strength. By now, it will become clear that the adaptive leadership approach is nonlinear compared to the traditional doctor–patient relationship, which tends to be linear.[17] Nonlinear in this context means the relationship between the two entities (doctor and patient) is not constant and has more variables to consider compared to a linear relationship, whereby it is more direct and obvious in terms of the interdependence. An observant and astute EP will be able to discern these as he broaches treatment options, risks, complications, and other factors.[1922]

The BRAVE framework

For EPs to be able to execute the adaptive leadership approach at the bedside, we propose a framework with the mnemonic, BRAVE [Table 2]. It is an original and unique model, summarized in a mnemonic which is easy to recall and apply at the point of care. In a hectic and busy ED, it is not uncommon for EPs to lose sight of some of the elements to be covered in their discussion. Thus, the simple to remember mnemonic can act as a “memory jolt.” The use of the elements in the framework can go further to strengthen the demonstration of the department's culture of compassion and patient-centric approach to care. With this, there is no reason why this adaptive leadership model cannot be executed in the ED, just as it can be applied in other settings or larger organizations. BRAVE, as a mnemonic, summarizes a few elements.

Table 2

Elements covered in the BRAVE model

Mnemonic	Elements
B	Behavior
	Beliefs
R	Relationships
	Resources
A	Advocacy
V	Values
E	Emotions and empathy
	Education
	End of life choices
	Ethics

Behavior and beliefs

B or “Behavior and Beliefs” reflect the positive or negative behavior of patients with regard to their health and healthy practices. Their belief refers to the conviction they hold true, which in turn can have an impact on their attitude and behavior. It is important for EPs to explore this at the point of care.

R: Relationships and resources

R or “Relationship and Resources” identify that the patient is not an isolated entity. He will have interaction with the EP, staff, his spouse and family members, the people at his workplace, his network, and the circle of contact in his community. These relationships are useful to know as they can influence his behavior and health identity. As for resources, these refer to the services and assistance that the ED patient may require, whether immediately or some time down the line. These would include community support services, medical social worker referral, financial assistance, step-down care, home nursing support, home hospice referral, counseling, mental health support, and other services. It will be good to create a directory of these for the perusal by the EP. Having an online platform or e-resources for this will be useful. In some cases, an application which can be deployed through EPs’ mobile devices also makes it very accessible.

A: Advocacy

A or “Advocacy” simply means engagement and speaking up for, or making representation for the patient. The EPs’ work at the front line exposes him to a wide variety of patients, from different backgrounds, including some very challenging circumstances. Through the adaptive leadership approach, the EP will be able to decipher more issues and challenges. He can thus attempt to effect change, whether in pathways, practice, or policy. If he feels strongly about any such issues, an EP may go the extra mile.[30] For example, some have gone on to work with nongovernmental organizations or support groups, to help correct or improve certain circumstances. To illustrate further, besides managing a technical problem an elderly patient has presented with, the EP may discover that he lives alone and is prone to frequent falls. The EP would then have to source for relatives or even community befrienders for support, short of having to admit the elderly into the hospital. Another patient with a nonhealing, infected, diabetic foot ulcer may have an occupation that requires him to put on safety boots/footwear throughout the whole 8-h shift. The EP may then go on to make representation to the employer on behalf of his patient for other options at work until his ulcer improves. An elderly who lives alone and presents frequently to the ED with a spectrum of somatic complaints may be lonely or depressed and could be matched with community befrienders or a neighborhood network circle to have friends visit them. All these patients present to the ED with more than just technical issues. Finding the root causes and exploring other collateral factors certainly requires lateral thinking and an adaptive leadership point of care model.

V: Values

V or “Values” refers to a person's life principles and priorities. A patient's values will affect his decisions, health preferences, and choices. When an EP engages his patient, these have to be borne in mind. It may explain why the patient makes a certain decision or chooses an option. This can certainly impact the care that is delivered. In the rapport with patients, an EP would have to listen attentively and filter out the relevant details. If the patient does not share his values openly, it may be entwined in his conversation with the EP. Using the adaptive leadership approach, the EP will be more attentive to such nuances and messaging, depicting the patient's values, which can affect his care. Patients’ values are critical motivational elements of their behavior and attitude.[313233]

E: Emotions, education, end of life care decisions, and empathy

An ED patient will experience a series of emotions. He may feel fear, worry, stress, loss of confidence or control, dissatisfaction (for a variety of reasons), anger, depression, apathy, and indecision among others. The triggering emotions commence at home or at the point when they encounter the emergency or crisis. En route to the ED, they will go through another series of emotions. On arrival at the ED, while they wait or during interaction with the EP, there will be other changes in their emotional states. It is crucial to understand this in order to demonstrate empathy and enhance the patient's care experience in the ED.[34] During the conversations and interaction, at any point where opportunity arises, the EP can strive to educate the patient and correct any misperceptions he may possess. This platform of communications presents a good opportunity not to be missed as at times patients may be more receptive to behavioral changes when they have been stricken by an acute illness. EPs also have to take note if their patients’ have any advanced care plans, advanced medical directives, or end of life care decisions made. In Singapore, this information is available on patient's electronic medical records and would be included in their confidential clinical records. These can affect care decisions. In case critically ill patients do not have these decisions made prior, EPs will have to broach the topic appropriately with patients or their family members and next of kin at the right time. End of life issues are complex and emotionally charged discussions which needs the adaptive approach. Using the SPECIAL end of life framework will enable an EP to execute this in a systematic and encompassing way, with the needed sensitivities. This is another example of a mnemonic to help with recollection of the pointers to cover in such discussions.[2635] Throughout all interaction and encounters with patients, it is always important that the EP must be empathetic and provide a listening ear to the patient. It will allow the EP to connect with the patient and provide the leadership and guidance that the patient needs. It is also important for the EP to know the difference between empathy and sympathy as this can very much change a patient's perspective of the EP and their encounter.

Ethical perspective

There is ethics in every patient encounter. In the ED, ethical issues that can potentially arise may be related to autonomy, efficiency, justice, proportionality, and health maximization, among others.[3637] In using the BRAVE framework, one may notice the overlap; for example, between values, beliefs, behavior, and ethics. Thus, the mnemonic should be used with some degree of flexibility. This is very similar to the “real world” context where things may not be readily segmented and may be intertwined. The BRAVE framework will also be dependent on other factors such as culture, religious background, and societal norms. Thus, it is important to realize the context EPs are working in. Moreover, the majority of people's thoughts, values, beliefs, and emotions are not usually obvious or overt. Like an iceberg, some 90% of these are submerged below the surface. EPs practicing adaptive leadership skills should be conscious of this and may help tease some of these out through their interaction and questioning approaches. Motivational interviewing can also be useful. After all, we must strive to support our patients. Despite the fact that they have an emergency to be dealt with, they should be comfortable and able to express or share their concerns, fears and opinion with us.[3839]

“BRAVE”: IN THE CONTEXT OF COVID-19

The COVID-19 pandemic is an unprecedented one, posing challenges on multiple fronts. It has been a unique test for leadership at multiple levels, as well as a challenge for every health-care provider. There were many ethical dilemmas, the need to be innovative in handling surge capacity, rationing and allocation of precious resources, competitive beds utilization, PPE (personal protective equipment) distribution, and many others. It also tested crisis leadership competencies in the whole healthcare sector; oversight, planning, coordination, resource distribution and sharing, collaboration, and review and reorganization of public health policies and mitigation. COVID-19 represented a good example of VUCAH. EP from around the world, were at the frontline, leading the way and working with many healthcare colleagues from the various disciplines.[404142]

The COVID-19 pandemic presented many technical issues. It enabled emergency and frontline physicians to relook (acute respiratory illness), review diagnostic steps, have pathways for managing high risk patients, instill new processes to reduce aerosolization and get familiar with the use of negative pressure and isolation rooms. Not to be overlooked as well is the spectrum of the “usual” ED patients who will continue to present with their emergencies. The range of adaptive issues and problems was even greater. These would include the emotional and psychological elements involved. There was much anxiety and uncertainty, especially in the early days of the pandemic and every patient needed reassurance. There was also an initial phase where there was public information overload, with the sharing on social media as well as the regular press reports, which may have been very confusing for the layperson. Concerns about their family members, especially the elderly and young was widespread and certainly valid. The economic downturn made financial concerns among patients a very real issue. Every EP may be asked more than the usual fair share of technical questions; thus, they would have to be very well informed and resourceful in every interaction with patients. Each interaction provided a platform for EPs to influence their patients adaptively, change their behavior, and alter their mindsets s relevant. This can be achieved with the lateral thinking each one of us can execute, using the BRAVE mnemonic to help remind us of what we have to cover. The synergies of handling the technical and adaptive issues together during the COVID-19 pandemic came across very clearly. Both the tasks and people orientated leadership competencies were necessary and had to be well integrated. The adaptive competencies allowed EPs to have the more systemic perspectives. Using the BRAVE framework, everyone can contribute and make the difference at the point of care.

Even as we expect so much from EPs at the frontline, their self-care, psychological safety, and health must never be overlooked. Their own beliefs and behavior, relationships and resources, values as a health-care professional, the many facades of their emotions and being advocates for themselves are just as important.[424344] The “BRAVE” model certainly can help them take stock of these very critical elements for their own wellness.

CONCLUSION

The adaptive leadership approach is becoming more important today, in the complex world we live and practice in. There is no running away from inculcating a higher level of emotional intelligence, embracing diversity of views, adapting to changes, as well as recognizing our feelings and needs, alongside those of our patients. EPs must continue to foster quality and meaningful relationships with their patients, despite the relatively short contact time they share.[4445] They must continue to learn and develop themselves, be innovative, not be afraid to test out new models of care and continue to remain creative and up to date. The BRAVE model of adaptive leadership application at the point of care in the ED represents another ‘tool’ EPs can find useful in their hectic course of work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.