The banner in front of the ED where I work proclaims “magnet hospital.” “Magnet” status tells patients and visitors that the care from nurses (and ED technicians and patient care associates staff under their auspices) is so good that the ED should be a magnet, attracting patients and nurses to come here and inspiring other EDs emulation.

For many years, our ED’s annual census has been 100,000 patients. One might think that, after the 99,000th patient, our “magnet” nursing and ancillary staff would:

• Gown patients if the chief complaint suggests likely examination of a clothes-covered body part (e.g., pelvis).
• Put telemetry leads and a pulse oximeter on patients with cardio-pulmonary complaints.
• Take the patient’s sticker label- and EKG-containing manila envelope when moving patients within the ED.

Stock each room so providers don’t scour the ED for urine cups, tongue depressors, lubricating jelly, etc. How embarrassing is it to have a patient in position for a rectal or pelvic exam only to find that, yet again, there’s no jelly in the room’s supply cart? How can I do a service recovery so my Press-Ganey score doesn’t plummet from that experience? I leave my patient for several minutes to search room-by-room in different ED zones for the jelly because the room next door doesn’t have it, the next, or the next. And, each time I enter a room looking for jelly, I apologize to a disappointed patient who is excited to see, for the first time in hours, a human being who may be their doctor.

It’s remarkable how often these simple tasks don’t happen, frustrating patients and physicians. The underlying reason for not achieving high-performing care in such circumstances is because many employees are task-oriented (e.g., “room” the patient), and not goal-oriented (e.g., ready the patient for examination).

Every team member should have the mindset not of “What’s the task?” but, rather, of “What’s the goal?” And develop habits to meet the goal.

I don’t blame ED technicians or patient care associates. Their boss doesn’t allow them to inquire or make judgments regarding whether the patient needs a gown. This is truly unempowering. Inquiring why someone came to the ED while escorting them to a bed, and determining whether they should be gowned, requires (non-medical) judgment but carries no risk. Most employees want to exercise judgment in their jobs. Functioning below your level of talent, credentialing, or licensure is unfulfilling and contributes to burnout.

Granted, not all work is glamorous. However, reframing one’s work as being for a higher purpose helps focus on the goal, not the task, and supports a mindset for developing and carrying out habits. Hospital janitors are happier when forming relationships with patients and framing their goal as helping patients recover better and quicker via a clean, peaceful environment, rather than focusing solely on the habitual tasks of mopping the room, wiping down surfaces, and removing garbage.

A parable conveys this poignantly: A traveler came upon three men working. He asked the first man what he was doing, and the man said he was laying bricks. He asked the second man the same question, and he said he was putting up a wall. The third man said he was building a cathedral to the glory of God that will serve as a testimony to the greatness of the human spirit, creativity, and engineering, and will last thousands of years. They were all doing the same work. The first man had a job. The second had a career. The third had a calling.

Administrators often do not encourage staff to conceive of work as a calling, develop goal-oriented habits, or work according to those habits. It’s no surprise, then, that we don’t achieve excellence in this.

The mindset of forming habits applies not only to staff but to physicians as well. Although physicians have much leeway and authority for judgment, we are quite habitual, trained to do certain things very routinely. We read EKGs and CXRs systematically, place and tie sutures methodically. Same way, every time, so we don’t make mistakes.

One side effect of this task-oriented, not goal-oriented, expectation among ED administrators is that physicians feel less motivated because our rate of work is severely constrained by others’ work. No matter how many times or what advice our boss tells us at our annual review about how to see patients faster, we’ll never be the rate-limiting step. No matter how fast we work, we’ll have to gown the patient, apply EKG leads, track down manila envelopes, and scour the ED for readily available supplies. Consequently, we feel no urgency to see non-sick patients quickly to improve access to care or throughput, “move the meat,” or generate corporate revenue and CEO income.

Organizational leaders need to develop a culture that values and creates habits in the service of a higher calling, one that achieves goals, not just completes tasks.

Deliberate practice toward mastery learning is one means to accomplish goal-oriented habit-forming. This involves choosing goals to be accomplished through habit, breaking down steps to achieve them, and having staff and physicians undergo repeated instruction and assessment in each step until they do them correctly, essentially subconsciously.

Aristotle said: “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.”

Our “magnet” ED loses many nurses to higher-growth opportunities. Lack of professional growth through training opportunities toward the habit of excellence contributes to job dissatisfaction. Many would like to learn point-of-care ultrasound (POCUS) to accomplish the goal of difficult peripheral intravenous line placement rather than just performing the task of attempting placement without POCUS and feeling defeated when unsuccessful. Our ED does not encourage the development of goal-enhancing nursing skills such as POCUS. Our nursing attrition demonstrates that “magnets” can repel as well as attract. Goal-oriented habit formation toward a higher calling can mitigate this.

The author is an anonymous physician.