Original research
available within limited hours, poorly functioning IT systems and rest spaces being in a different building. So you’re just basically sharing (toilets) with the patients. In the ur- gent care centre there’s two toilets for the whole of the department in there, often one of those is broken…and not enough lockers for every member of staff. (ACP, G2) Stuff like working computers, a consistently working POD sys- tem… those little things I think make a bigger impact on your life than how many people come in through the front door. (Trainee, G5) A lack of physical space for administrative tasks was high- lighted by many clinical staff, being described as ‘woefully inad- equate’ (ACP, G2). Wards were described as ‘unfit for purpose ’ (Nurse, G11), which was attributed, in part, to higher manage- ment lacking understanding of the needs and practices of the ED. One example highlighted the long-term impact of ED work- space changes that were not fit for purpose: …it was clear that no clinical staff had been involved. Doors were in the wrong space, no sinks in the right place, not enough storage, poor flow, poor layout (ACP, G2) Existing rest spaces or staff rooms were reported to be taken over to provide more clinical room, limiting the space for staff to change, rest and decompress. The nurses were getting changed in a corridor, now they seem to have a cubicle they can get changed in. But the facilities for the same trust are really very different. (Nurse, G10) This was perceived to be particularly important due to working in the high-pressure environments of a crowded ED, where staff voiced concerns regarding the sustainability of working with a high workload safely without private spaces. EDs were perceived to be more busy, for reasons associated with shifts in societal expectations and perceptions of the scope and role of ED: Go back ten years ago in the emergency department and people would try their best at home, would take painkillers, will see how it goes, not wanting to trouble A&E, but seems like now it seems like A&E is the open door for everybody just to come in with ev- erything. (ACP, G7) Participants used emotionally laden language when describing the intensity of the workload itself, with parallels drawn between being at war and working on the NHS frontline, where staff worked under similar levels of intensity but longer term and without rest. …when people are deployed (in the forces) they are deployed for 6 months…because that 6 months is intense, it’s intense on your body, it’s intense on your mind, it’s intense on your family, it’s in- tense on everything about you, and that’s while you were deployed for 6 months, and then there’s some recovery time coming back. (Consultant, G4) Comparisons were also made to the sinking of ‘the Titanic’: There is the jollying everybody along, being the redcoat on the shift, cheering everybody up, saying everything is going to be okay, but feeling like you’re just rearranging the deckchairs on the Titanic (Nurse, G10) The impact of a consistently high workload was described as being compacted by a lack of agency and autonomy over working patterns, which was perceived to be related to non-clinical staff making decisions about shifts without understanding the inherent pressures:
anxiety over how they might be perceived by peers, but particu- larly by senior colleagues: That’s a classic example… she’s a senior member of the team, really knows her job…. She was quite critical really, in a very negative way about how you managed that patient. (Nurse, G11) Some participants reported senior colleagues having unreal- istic expectations of the more junior staff, with little considera- tion of the increased pressures that have arisen in recent years: It’s ridiculous to compare the needs, even for our senior colleagues who were registrars five years ago, the reality of running the de- partment overnight is not the same as it was then. (SAS doctor, G1) Existing structures and working practices of the NHS were described as ‘archaic’ and ‘old fashioned’, leading staff to feel blamed if they could not cope with the pressures and disempow- ered to seek support due to the expectation that they should be ‘unbreakable’ (Trainee, G9). Participants also voiced that they were unclear on lines of accountability, who to approach for what problem. This barrier to escalating their concerns was further compounded by the belief that both clinical leadership and higher management were generally overburdened and unre- ceptive to discussions on workplace concerns. Increasing pressure and longer waiting times were described as driving antisocial behaviour from patients, exposing staff to risks to physical and psychological well-being: So the long wait causes verbal or physical violence and aggression, which has a massive impact on staff well-being. (Nurse, G11) Participants highlighted the desire to be supported to learn from difficult experiences and develop in light of them, suggesting that a simple checking in on how individual staff members are progressing would be well received and beneficial to well-being: We have intermittent debriefs… but it’s not every time. It doesn’t necessarily need to be every time, but it’s not as frequent as it should be. Even if it is just ask are you okay? (Trainee, G5) Interprofessional respect and development of a more empathic culture of shared responsibility were flagged as key opportuni- ties for change that would support better team cohesion: We need to change how we speak and respect each group, and we need to try and understand each other’s point of view, and if we could get better ways of working, but just talking to each other about what are my problems, what are your problems, why is this stressing you, what’s stressing us, how can we work together to do that. (ACP, G2) Findings suggest that EM professionals are confronted with outdated perceptions of clinical demand from within teams and systems, with unrealistic expectations which compound a blame and shame culture when expectations are not met. Operating within this chronically under-resourced system was framed as compromising workforce well-being and risking burnout, yet participants indicated that simple interventions such as check-ins, clearer lines of accountability and a more civil and respectful culture would offer key opportunities for growth and sustainability even in the face of a staffing crisis. Untenable work environments The complex work environment within the ED was described as being of significant concern, compromising care and leaving staff feeling undervalued due to basic needs being unmet. Participants frequently reported poor quality or inadequate facilities, such as provision of toilets, lockers and changing rooms, hot food only
Daniels J, et al . Emerg Med J 2024; 41 :257–265. doi:10.1136/emermed-2023-213189
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