Original research
The people who control our rotas are… her job is a rota co- ordinator, she works in an office, she is administrative, and the person who signs that off is the manager for the department, again non-clinical, and getting leave is a nightmare, it’s awful. (Trainee doctor, G5) Consultants identified that there were limited options to reduce workload when approaching retirement, and they did not necessarily feel well-equipped to continue operating under high pressure and for long hours. Those in training posts reported insufficient time to meet requirements or study due to workload, influencing both career progression and confidence in the role. You are getting no progression because you’re not getting your training, and I know that personally in the last year I made my decision that I will not continue to work clinically, I will step back in the next few years because there’s… why would I stay doing something that there’s no reward for? (Nurse, G11) Participants agreed that there was both a need and an oppor- tunity for the ED to be a ‘nicer place to work’ (ACP, G2). Specific suggestions included a full staffing quota, ensuring staff are adequately rested to return to work and the opportunity for peer support: My top three things would be coming on with a full staffing quote so you know there’s no gaps in the rota, so you’re all there. Every- one is well rested and ready for the shift, just being able to talk to each other on the shop floor and being quite open with each other on how everyone is feeling. (ACP, G7) Many of the suggested changes directed at making working conditions in the ED more sustainable related to basic needs such as being able to take breaks, access healthy food and functioning IT when needed: …having those opportunities to go off and have a five minutes when you need to, to be able to continue your shift. (ACP, G7) It would be really nice to be able to have some healthy nice food in the department. (Nurse, G11) As more and more of our job goes electronic, electronic notes, elec- tronic prescribing, actually having IT systems that are fit for pur- pose, everyone has access to (Trainee doctor, G9) Self-rostering was frequently mentioned as a positive experi- ence for participants and a useful avenue to help participants to deliver better care and improve well-being: One day off between a set of shifts is not enough to decompress and be re-energised to start back on your next set of shifts. So I think the rota, we have moved to a more self-rostering method now, and I think that’s helping with staff well-being, especially in our team. (A7) Overall, working in existing ED environments was described as ‘untenable’ and ‘unsustainable’ in terms of both the working environment and the lack of agency and autonomy over high- intensity workloads. Many of the problems and solutions relate to provision of resources to meet basic needs, many of which are subject to professional and NHS regulations; however, due to pressures this is not being implemented. Compromised leadership Clinical leads in the ED were perceived to hold responsibility for setting the tone for culture and behaviour in the ED, leading by example: And you lead by example as well, so if your consultant in charge is not taking a break you feel like you can’t ask to take a break. It’s the same with the nurses, if the nurse in charge is not taking a break
then a lot of the junior nurses won’t come and ask for a break be- cause again you’re guided by the leadership aren’t you? (A7) The clinical lead in the ED is a key conduit for change, from a cultural and environmental perspective especially. However, participants expressed frustration about feeling that their voices were not heard or valued outside of the department, in part due to clinical leads being reluctant to escalate their concerns due to the discrepancies between clinical priorities within the ED and the priorities expressed by trust level executive management: You’ve got the clinical side, and we are to one degree or another worried about the patients, and then you have got the management side and they are worried about figures, times or money, and those two things don’t really mesh together (ACP, G2) Yet, within the EDs, leadership was described as being poorly supported in terms of protected time to train and deliver the role fully. Consultants voiced reluctance to take on a leadership role due to lack of ‘visible leaders’ to provide inspiration or exemplar: ‘There is no one for us to look up to, to lead us’ (Consultant, G4), ‘We need compassionate leadership’ (SAS doctor, G1). A lack of definition or clear understanding of what the clinical role entailed was reported to make it difficult for clinical leads to be effective in their role: People tell you that you’re there to lead, and you’re like I know but what does that mean? And then you don’t know if you’ve got to go to all these meetings, which ones you really need to go to, which ones can I not go to, also for me I do the job on my own. (Clinical lead, G6) Participants emphasised they need a ‘clear definition of what the college would see the role to be, and how much time they would expect it to take of your job ’ (Clinical lead, G6). Any possibility for growth was hampered by a lack of training or support from colleagues to help with even the practicalities of the role (such as recruitment and personnel management): I have literally started last week on a leadership course that’s been for other clinical leads in the organisation. But I feel a bit could have done with this maybe earlier. But that’s more about your leadership qualities and conflict resolution, it’s all that side of it as opposed to the actual practicalities of the job. (Clinical Lead, G6) When considering possible solutions to these difficulties, participants suggested that an accessible time to do the job and an online repository may offer an opportunity to share resources, learn from one another and foster development: I think sharing all the stuff we shared on the WhatsApp, trying to share stuff, so how to write a business case, what you need to do. (Clinical lead, G6) I should be doing work at a time I am getting paid, so you need to give me that time. (Trainee doctor, G9) Mentorship was also deemed to be important for successful delivery of the role: I think personally as leads and stuff we should all have some kind of mentoring type…Supervision, that’s the thing, we don’t get any. (Nurses, G10) Participants described having difficulties feeding into emerging issues to address unmet need, blocked from commu- nication with leaders by ‘layers of bureaucratic sediment’. This was compounded by the career trajectory of NHS management, where often those in post would swiftly move on for promotion. Overall, clinical leadership within the ED was described as compromised, unsupported and, ultimately, a key barrier or missed opportunity for change in culture and working practices
Daniels J, et al . Emerg Med J 2024; 41 :257–265. doi:10.1136/emermed-2023-213189
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