Original research
N=33 (28% of total responses). Due to higher response rates from doctors, these focus groups were further grouped by grade; nurses and ACPs were grouped by profession only and were organised base on availability. There were 11 groups in total (see table 1). Participants were mostly female, and from a white British background. Ages were spread fairly evenly across the categories, except ages 35–44 which included substantially fewer participants. Analysis Following analysis of the qualitative data, four key themes were generated. These were termed: ‘culture of blame and nega- tivity’, ‘untenable working environments’, ‘compromised lead- ership’ and ‘striving for support’. Data within these themes that were identified as ‘barriers’ or ‘opportunities’ for change were extracted (table 2). Illustrative participant quotes are identified by researcher codes, which reflect the profession and a recoded group number, to preserve anonymity. Culture of blame and negativity When asked about the most difficult aspects of their working conditions, participants commonly reported a culture of blame and negativity in the ED. The work culture not only felt unsup- portive and ‘toxic’ but had a marked effect on well-being. Partic- ipants described a culture which was quick to blame rather than support: You worry about making a mistake, and if you did make a mistake who would have your back. (ACP, G7) You very rarely get anyone saying that was a good job. (SAS doctor, G8) This was particularly felt top-down, where those in manage- ment position were perceived to take an unsympathetic view of extended waiting times and unmet targets, despite the tangible constraints of operating at overcapacity and ‘exit block’, prob- lems that participants perceived to be out of their control. Partic- ipants in all groups indicated that the negative culture instils
Table 1 Participant and focus group characteristics Characteristic n=33
n per group (% of total)
Professional groups
Medical staff groups
20 (60%)
Consultant grade doctors Consultant grade doctors
3 3 2 4 4 2 2
Postgraduate doctors in training Postgraduate doctors in training
Specialty and associate specialist doctor Specialty and associate specialist doctor Consultant grade doctors—clinical lead role
Nursing staff group
8 (24%)
Nursing staff Nursing staff
6 2
Advanced care practitioner group Advanced care practitioners Advanced care practitioners
5 (16%)
3 2
Gender
Female=24 (73%) Male=9 (27%)
Age
25–34 years old=8 (24%) 35–44 years old=4 (12%) 45–54 years old=8 (24%) 55 years or above=7 (21%) North East Scotland=1 (3%) North East England=2 (6%) North West England=1 (3%) East of England=2 (6%) West Midlands=3 (9%) South East England=3 (9%) South West England=11 (33%) East Midlands=2 (6%) London=6 (18%)
Geographical spread
Ireland=1 (3%) Missing=1 (1%)
Ethnic origin
English/Welsh/Scottish/Northern Irish/British=28 (85%) Indian=3 (9%) White and black African=1 (3%) Any other white background=1 (3%)
either did not consent or were not eligible based on their role and/or department. From the remaining 46 respondents, 13 of these could not attend or cancelled, leaving a final sample of
Table 2 Primary concerns, barriers and opportunities for change Primary workplace concerns Barriers to changing working conditions
Opportunities for change
► ► Negativity and toxicity among colleagues ► ► ‘Outdated’ perceptions of clinical demand ► ► Expectations and frustrations from those we care for ► ► Lack of investment in staff development
► ► Interprofessional valuing and respect ► ► Culture of care and shared responsibility ► ► Team cohesion ► ► Clearer lines of accountability ► ► Nurturing growth
Culture of blame and negativity
► ► Understaffing and high workload ► ► Unmet physical needs ► ► High-intensity workload ► ► Lack of autonomy over working patterns ► ► The shifting nature of work
► ► Viable staff ratios ► ► Access to hot food and rest spaces ► ► Protected study time ► ► Self-rostering ► ► A department that is well-resourced and fit for purpose
Untenable working environments
► ► Team expectations of their leaders ► ► Realities of working as a clinical lead ► ► Bridging the gap between the ED and executive management
► ► Compassionate leadership ► ► Role clarity ► ► Shared resources ► ► Access to mentors and coaches ► ► Protected time to do the job
Compromised leadership
Access to leadership training and support
► ► Access to support ► ► Mental health stigma
► ► Protected time to access support ► ► Prioritisation of well-being in the ED ► ► Embedded psychology ► ► Peer-to-peer support ► ► Levels of care, tailored to need
Striving for support
Daniels J, et al . Emerg Med J 2024; 41 :257–265. doi:10.1136/emermed-2023-213189
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