Original research in the ED. However, there were clear indications of opportuni- ties for growth and change, including a need for compassionate leadership, shared resources, time to do the job and mentorship. Striving for support This final theme encompasses the concerns raised by participants regarding well-being and staff support, specifically the barriers to accessing well-being support and their preferences in relation to what changes are likely to improve their well-being. Common barriers included having to attend support or well-being services during time off, with the scheduling of support geared to a ‘nine to five’ non- clinical workforce (ACP, G2). Mental health stigma in the ED was also cited as a key barrier. I think for me it still feels like a bit of a stigma about saying I am struggling what should I do next. (Nurses, G11) There’s nowhere that I can express how I am feeling or even under- stand how I am feeling. (Consultant, G4) This was reinforced by well-being not being viewed as a priority, with team check-ins or formal appraisals described as having ‘nothing in there about wellbeing’ (Clinical lead, G6), despite suggestions that simple well-being check-ins would suffice. Participants suggested that support should not be purely accessed after the fact but something that should be prioritised and routinely available to staff to safeguard mental health: … psychological support…it shouldn’t be something that we access when there is a problem, it should be something where we go well every month on a Friday at this time I go and talk to someone about what I have seen. (Trainee, G9) Participants’ lack of understanding about which services were being offered was raised by many, with participants often able to list services available, or where the staff support centre was based, but not how or when one might access them. This offers a key oppor- tunity for collaboration between staff support services and the ED to develop clearer pathways or a clear role for a departmental well- being lead. Peer support was consistently highlighted as a highly valued resource that should be considered part of supportive culture ‘gives you somebody else to share the load with, and not be that single voice’ (Trainee doctor, G9). However, limited physical space and time to engage in peer activities were cited as barriers: Well yeah it would be lovely to sit down and chat with my peers, apart from the fact that 1) we’re constantly busy, 2) we don’t have anywhere where we can sit and have a confidential gas. (SAS doc- tor, G8) Overall, accounts suggested that existing support was largely unfit for purpose, and where it was easy to access (such as peer support) and available, it was often incompatible with ED working practices and within a culture where seeking support was often stigmatised. Some participants expressed that having a psychologist embedded within the department was highly valued as a resource, particularly the different levels of support dependent on need: …(during the pandemic) we setup weekly drop-in sessions with the psychologist… and it was really great for a lot of people to be able to drop-in, and then that led on to having one to one for people who felt they needed that, and also within ED we had a psycholo- gist come round to our supervision when we needed them. (ACP, G7) Participants reflected that psychological input introduced in response to the impact of the COVID-19 pandemic was highly valued. While many were open to discussion about their mental
health and well-being, for many, stigma still permeates the ED culture and is further compounded by poor understanding and communication of available resources. Appointment of well- being leads, more value placed on well-being (including informal peer support) and routine access to psychology are suggested as opportunities to make strides towards improved well-being. Discussion This study identified four key themes describing the difficulties in the ED work place. Working culture, physical working environ- ment, pathways to care and leadership represent the core workplace concerns within our sample. These issues were perceived to play an instrumental role in their ability to sustain good working practices, well-being and, importantly, their intention to leave. Participants identified key barriers and opportunities within their work contexts which resonate with existing research and policy and can be used to shape the future policy and research development. 22 2 5 These find- ings act as a basis for the development of specialty-specific targets for change that are aligned with the views and voices of those working in this working environment and also take account the barriers and opportunities faced in the fast-paced unique environment of the ED. For a full set of EM-specific recommendations to underpin change across all of these four areas, see the Psychologically Informed Practice and Policy (PIPP) recommendations (https://rcem.ac.uk/ workforce/psychologically-informed-practice-and-policy-pipp/) Several of our findings have been noted in previous studies, partic- ularly the role of culture, environment and access to support. 22 Most of the research examining factors associated with working conditions and retention in EM are profession specific 3 6 18 19 and are not readily generalisable to other professional groups in the ED. However, our study included doctors, nurses and ACPs from which emerged common cross-cutting themes affecting all of these professions working in the ED, themes which are consistent with the broader literature 9 10 but specific to the EM working environment. As reflected in the work by Darbyshire et al , 5 the nature of the problems described were systemic; the workplace challenges were interrelated and appeared reciprocal in influence, arguably main- taining one another. The cyclical nature itself proves a key barrier to change, which raises the question: which is the primary target to effect most change? Leadership has a pivotal influence across these themes and is unequivocally vital to workforce transforma- tion; however, this is an area that has been largely neglected in EM, with very little research seeking to develop or evaluate leadership interventions in this environment. Indeed, there is an assumption that leadership naturally develops over time and is fully formed on appointment to the role. 23 However, leadership within the ED is particularly complex and demanding due to the range of compe- tencies required (clinical, managerial and administrative) 23 and the high-pressured environment within which this role needs to be delivered. This warrants tailored training and support to fully succeed. In settings where the nature of the work is unpredict- able and at times clinically critical, leadership is pivotal to patient outcomes and team functioning, 23 24 which are particularly crucial in the ED setting. Leadership has the potential to be a powerful driver in workforce transformation, cultural change 25 and team functioning within these highly skilled, professionally interdepen- dent teams. 26 To fully harness the capacity of leaders as agents of change, those in leadership positions must be sufficiently skilled, 27 feel supported to act on important issues 27 and have time to do the job. Yet, participants in this study reported poor role definition, lack of training and absence of protected time to deliver the role. This was compounded by blurred lines of accountability that led to impotence to effect change.
Daniels J, et al . Emerg Med J 2024; 41 :257–265. doi:10.1136/emermed-2023-213189
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