Original research
Implications The development of leadership in EM should now be a primary focus. There are clear steps that can be taken to begin to mobilise and maximise the pivotal influence of leadership in effecting change, across government, professional, organisational and individual levels. On a public policy level, there has been a rapid growth of govern- ment level publications and resources to recognise the role of lead- ership as a conduit to better patient and team health. 28 However, recommended leadership training is often generic and never mandated. This is surprising given the clear links with patient safety and team functioning. 23 24 Leadership training in healthcare should be mandated by government bodies, not least due to links with patient safety. 29 Significant work has been undertaken by RCEM to integrate and embed mandatory leadership training into the training curriculum for EM trainees, without which they cannot progress. While this demonstrates forward thinking and some future-proofing for the medical profession, it cannot cease at this point, it must be supported with continuing professional development post-training. The rele- vant professional bodies provide access to good quality leadership training such as the RCEM EM Leaders Programme and the RCN Leadership Programme, however, this is largely online without protected time to access or support development. More work is needed to ensure leadership training is visible, supported as part of a workplan, and a priority area championed by all relevant profes- sional bodies. Further work is needed to ensure that leadership competencies are introduced at an early stage of training 23 so the necessary skills are embedded and cultivated on the pathway towards and within leadership roles, rather than ad hoc when necessity dictates. This falls to both training and professional bodies to work together to ensure that theory-driven leadership is a core part of the teaching curriculum, with mentorship and practical resources (such as role definition, a personal development plan, human resource support) to complement and facilitate the necessary continuing professional development throughout a clinical career. Responsibility then moves to the employing local NHS trusts to support the development of those individuals within leadership positions. It is at this level that ED clinical leads and their teams can harness their influence; local NHS trust policies are driven by guidance from government and professional bodies, however, they have the power to shape local policy and mandate change in view of the needs of a service. We summarise key recommendations to underpin change at a local NHS level in Box 1. Appointment of well-being leads within the ED, as outlined in the RCEM PIPP recommendations 30 and other key documents, 22 is also a key step towards workplace transformation through leadership; however, it is imperative this role is also supported with protected time and development. A well-being lead with a clearly defined remit and role would play a pivotal gatekeeper role in encouraging attitudes towards well-being in the ED by delivering ‘warm hando- vers’ and well-being initiatives, such as informal check-ins, staff team activities (ie, safety huddles), and well-being surveys. On an individual level, those in leadership positions are more likely to succeed by harnessing the influence and opportunity that accompanies the role, identifying and taking inventory of challenges and barriers, clarifying lines of accountability to drive forward change and advocating for the needs of their team. Two mechanisms by which leadership bears the greatest influence include leading and prioritising a continuous cycle of quality improvement (eg, autonomy over work patterns, access to rest spaces, patient flow, taking steps to address the diversity gap) and role modelling of positive profes- sional behaviours. 26 The latter includes compassionate and inclusive
Box 1 Key leadership recommendations for local NHS trust level commissioning
attributes but also speaks to the necessity to meet basic needs: taking breaks, adhering to annual leave, destigmatising views on mental health and openness to learning and change. Those in leadership roles should be encouraged to engage with the leadership networks, broadened to encompass a platform or virtual environment (ie, repository) to share and access resources and be granted access to leadership consultation with the well-being team as and when neces- sary. Those in leadership positions should also be provided with clear referral processes and internal professional standards to help address any incivility, including bullying, harassment and issues of inclusion. This would help promote a culture of care and interprofessional valuing and respect, improving team cohesion. Finally, it is imperative that lines of accountability are clear for those in a leadership position. While many NHS trusts differ in their management structures, each trust will have communication path- ways to divisional and executive management leadership teams. In order to drive the full potential of leaders to action change through these mechanisms, it is fundamental that pathways from ‘shop floor’ to the chief executive are clear and opinions and concerns of ED leadership are welcomed. Flow through the ED, staff ratios, pay and pension structures are of course prime targets for change and where the current high- profile focus lies. However, leadership is a key conduit to change and those with mandatory powers must now move to recognise this in order to unlock the full potential of this role. Limitations and future directions There are inherent limitations in the small size of some of the partic- ipant groups, and as such the views and opinions expressed cannot be considered transferable across their respective professions. While many prospective participants did not proceed to focus group meet- ings due to last minute requests to cover shifts, the participant pool was comfortably within the bounds of what is acceptable for a qual- itative study. ⇒ ⇒ Those in leadership positions should be supported to attend leadership training as part of their workplan, within their workplace hours. This would include top-up training and training assignments. ⇒ ⇒ Support to engage with a leadership mentorship or coaching programme as part of their workplan, with a view to continuing professional leadership development and creating safe spaces to problem-solve, reflect and seek support. ⇒ ⇒ Access to the consultation service within the local NHS staff support services. ⇒ ⇒ Appointment of a designated ‘Wellbeing Lead’ with protected time and support to deliver the role. ⇒ ⇒ Clear description of roles and responsibilities, to include protected time dedicated to undertaking additional responsibilities associated with a leadership role and a professional development plan that is reviewed annually. ⇒ ⇒ Support to engage with the EM clinical lead network in order to access resources to support the delivery of the role and access peer support when necessary. ⇒ ⇒ Clear lines of accountability at an NHS organisational level with identified pathways to escalate concerns. EM, emergency medicine.
Daniels J, et al . Emerg Med J 2024; 41 :257–265. doi:10.1136/emermed-2023-213189
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