Researchers from the University of Bath with the Royal College of Emergency Medicine (RCEM) investigated perceived barriers that may be inhibiting the implementation of working conditions and practices in UK Emergency Departments (EDs), and the potential opportunities for policymakers to redress the balance.

The Psychologically Informed Policy and Practice Development (PiPP) Study, led by Senior Lecturer and Clinical Psychologist Dr Jo Daniels, is the first study of its kind to outline issues associated with work satisfaction and retention in UK EDs.

The study builds on previous work - the Covid-19 Clinician Cohort (CoCCo) study model, which highlighted a model and pathway of psychological care for NHS frontline doctors, which has been adopted in clinical services, research that sought to address the mental health needs identified in their earlier work.

Participants recruited for the study comprised of doctors, nurses, and advanced care practitioners (ACPs) who worked in NHS Emergency Departments across the UK. These three groups represented the majority of the EM workforce and core affiliates of the RCEM.

Analysis from the focus groups generated four key themes when considering barriers to change and staff retention in NHS Emergency Departments:

• ‘culture of blame and negativity’
• ‘untenable working environments’
• ‘compromised leadership’
• ‘striving for support’.

These themes were identified to underpin issues related to retention and identify opportunities for change, developing a set of evidence-based recommendations specific to the needs of this emergency care specialty. Authors identify NHS leadership as a core focal point for future focus and develop as they act as potential conduits for change, across all dimensions.

Dr Jo Daniels and her team also interviewed three top comedians, Adam Kay, Phil Hammond, and Harry Hill - on why they left the NHS, and how their experiences fit with the research findings.

'A culture of blame and negativity'

The culture in the ED was perceived as a hierarchical, stigmatising culture that is laden with blame and hostility. Described as ‘old-fashioned’ and ‘archaic’, the work culture not only felt unsupportive and ‘toxic’ by participants but had a marked effect on staff wellbeing.

“No one was interested in us as people”, said comedian Harry Hill, due to the outdated perceptions of clinical demand from within teams and systems, with little consideration of the increased pressures arisen in more recent years.

Harry Hill captures this when describing his experience as a former medical doctor working in the ED.

'A badge of honour to work as hard as possible'

Writer and comedian Dr Adam Kay, previously a doctor in the NHS, describes the ED culture as “a culture whereby it's a badge of honour to work as hard as possible.”

Such unrealistic expectations compound a blame and shame culture when expectations are not met. As such, staff felt blamed if unable to cope with the demands of the service, and disempowered to seek support as they should be ‘unbreakable.’

Adam Kay also talked about his personal experience when asking for support, with senior clinicians ‘belittling’ his struggles and not providing the necessary support.

To help cultivate a culture of care and shared responsibility in the ED, participants in the study suggested simple steps such as informal check-ins and the provision of clearer lines of accountability, suggestions that feature in many guidelines and recommendations but failed to be implemented because they are not mandated.

There was some indication of optimising team cohesion, however interprofessional respect and nurturing development of individuals and teams was the key missing ingredient.

'An unsustainable working environment'

Participants described the complexity of working in an ‘untenable’ environment within the ED – a work environment “unfit for purpose”, compromising patient care and leaving staff feeling undervalued due to basic needs being unmet. Existing facilities were reported to be inadequate.

These ranged from “sharing toilets with the patients”, through poorly functioning IT systems, to the absence of rest spaces and staff rooms. This leaves ED workers without private places to change, rest and decompress due to the high workload of a crowded ED, which is as “intense on your body” as “on your mind.”

Dr Phil Hammond addresses a few of the issues that constitute the current pressures of a demanding ED, contributing to an ‘unsustainable’ working environment.

'Self criticism'

Insufficient protected time to study also played a pivotal role in exacerbating participants’ feelings of inadequacy towards the complex ED work environment, influencing both career progression and confidence in the role.

Phil Hammond explained that ED staff do not have granted access to protected training because of service provision and long waiting lists, saying that doctors are “very self-critical” given a lack of supervision.

'Goodwill wearing thin'

When considering how staff continue to work in such difficult conditions, for so many years, Harry Hill highlighted the force for good that has traditionally motivated NHS staff, but suggested this is finally wearing thin.

When considered what felt necessary to move forward, viable staff ratios, adequate rest facilities and protected study time were all aspects which staff felt needed to be addressed to address issues of wellbeing and retention.

Better access to IT and autonomy over working patterns were also flagged as vital areas that would improve working life if addressed.

'Compromised leadership'

The concept of leadership was raised frequently when discussing the expectations of those in leadership positions within the ED; a key barrier to cultural change and improvements in working practices in ED.

Considerations regarding the nature of the leadership role and the challenges encountered by those in such positions were described by clinical leaders.

“These consultants are generally defacto managers, often of a relatively large number of people, who haven't really had enough training,” said Adam Kay.

In the study, consultants voiced reluctance to take on a leadership role because of the lack of training and support from colleagues to help with practicalities of the job. Participants also expressed the need for ‘compassionate leadership’ guided by ‘visible leaders’ to provide inspiration and example to efficiently deliver the role, as well as a clear definition of what the role entails.

Adam Kay commented on the absence of leadership training, making them less prone to address and deal with mental health issues that might be reported by their team.

'Lack of leadership training'

When asked about potential interventions to enhance leaderships, participants proposed to broaden the clinical lead network, including an online platform where resources can be shared and accessed (e.g., repository), and engage in mentorship programmes.

Philip Hammond suggested: “We need to say to doctors one really interesting career pathway for you is to get involved in NHS management and clinical leadership. And not in a way that says we have gone over to the dark side.”

'Striving for support'

Philip Hammond explained: “Doctors have always been really hard to lead... There have always been those mental health issues, and we struggled to talk about them and hid them with drinking and all the other unhealthy things. There are far more people now talking about than they used to.”

However, participants in this study voiced concerns regarding wellbeing and lack of staff support initiatives, claiming that there is “nothing in there about wellbeing” within the department.

Mental health stigma was cited as one of the key barriers to accessing and seeking support, still permeating the ED culture; this was reinforced by wellbeing not being viewed as a priority, further compounded by poor understanding and communication of available resources. Another common barrier was represented by having to attend wellbeing services during time off due to the high-intensity nature of the workplace.

Adam Kay suggested that medicine, compared to other professions, is particularly inclined to mental health stigma – a 'big issue' whereby those in the healthcare sector might fear communicating about their mental wellbeing by compromising their professional reputation.

Mental health stigma was also highlighted as preventing people from seeking and asking for the support they need, further limiting the understanding about which services are being offered and what choices are available for staff to safeguard their mental health.