The psychological health and well-being of emergency medicine consultants in the UK

Retaining doctors in emergency medicine: an ethnographic study of emergency departments in England

OBJECTIVES

To gain a deep understanding of factors driving retention in emergency medicine. To understand in detail the day-to-day lived experience of emergency medicine doctors, to identify and explore factors influencing retention, to situate these descriptions within the current educational and health policy contexts and to advance the debate and make policy and practice recommendations.

DESIGN

Ethnography and semistructured interviews.

SETTING

Two purposively sampled emergency departments in England, with additional interview participants recruited via social media and relevant stakeholder organisations.

PARTICIPANTS

41 interview participants comprising 21 emergency physicians across 2 sites, 10 former emergency physicians and 10 stakeholders, with 132 hours of observation over 11 weeks in one emergency department in England.

RESULTS

Three key themes were developed as relevant to the day-to-day lived experience of work in the emergency department, presenting challenges to retention and opportunities for change. First, emergency physicians needed to develop workarounds to mitigate the sensory and material challenges of working in a difficult environment.Second, education influences retention through valuing, fostering competence and entrustment and supporting interdependence. These were primarily observable in the workplace through senior staff prioritising the education of more junior staff.Third, community was important for retention. Linked to education through communities of practice, it was built by brief interpersonal interactions between emergency department workers.Situating these descriptions in current policy contexts identified less than full-time working, portfolio careers and mentorship as retention strategies. Self-rostering and annualisation facilitated these retention strategies.

CONCLUSIONS

The emergency department represents a difficult environment with many challenges, yet by focusing on how doctors navigate these difficulties, we can see the way in which retention occurs in everyday practices, and that valuing staff is critical for retention.

Emergency department workforces' experiences and perceptions of well-being from an international perspective: a scoping review

OBJECTIVES

To identify and present the available evidence regarding workforce well-being in the emergency department.

DESIGN

Scoping review.

SETTING

The emergency department (ED).

DATA SOURCES

CINAHL, MEDLINE, APA PsycINFO and Web of Science were searched with no publication time parameters. The reference lists of articles selected for full-text review were also screened for additional papers.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

All peer-reviewed, empirical papers were included if: (1) participants included staff-based full-time in the ED, (2) ED workforce well-being was a key component of the research, (3) English language was available and (4) the main focus was not burnout or other mental illness-related variables.

RESULTS

The search identified 6109 papers and 34 papers were included in the review. Most papers used a quantitative or mixed methods survey design, with very limited evidence using in-depth qualitative methods to explore ED workforce well-being. Interventions accounted for 41% of reviewed studies. Findings highlighted pressing issues with ED workforce well-being, contributed to by a range of interpersonal, organisational and individual challenges (eg, high workloads, lack of support). However, the limited evidence base, tenuous conceptualisations and links to well-being in existing literature mean that the findings were neither consistent nor conclusive.

CONCLUSIONS

This scoping review highlights the need for more high-quality research to be conducted, particularly using qualitative methods and the development of a working definition of ED workforce well-being.

Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study

BACKGROUND

Staff retention in Emergency Medicine (EM) is at crisis level and could be attributed in some part to adverse working conditions. This study aimed to better understand current concerns relating to working conditions and working practices in Emergency Departments (EDs).

METHODS

A qualitative approach was taken, using focus groups with ED staff (doctors, nurses, advanced care practitioners) of all grades, seniority and professional backgrounds from across the UK. Snowball recruitment was undertaken using social media and Royal College of Emergency Medicine communication channels. Focus group interviews were conducted online and organised by profession. A semi-structured topic guide was used to explore difficulties in the work environment, impact of these difficulties, barriers and priorities for change. Data were analysed using a directive content analysis to identify common themes.

RESULTS

Of the 116 clinical staff who completed the eligibility and consent forms, 46 met criteria and consented, of those, 33 participants took part. Participants were predominantly white British (85%), females (73%) and doctors (61%). Four key themes were generated: 'culture of blame and negativity', 'untenable working environments', 'compromised leadership' and 'striving for support'. Data pertaining to barriers and opportunities for change were identified as sub-themes. In particular, strong leadership emerged as a key driver of change across all aspects of working practices.

CONCLUSION

This study identified four key themes related to workplace concerns and their associated barriers and opportunities for change. Culture, working environment and need for support echoed current narratives across healthcare settings. Leadership emerged more prominently than in prior studies as both a barrier and opportunity for well-being and retention in the EM workplace. Further work is needed to develop leadership skills early on in clinical training, ensure protected time to deliver the role, ongoing opportunities to refine leadership skills and a clear pathway to address higher levels of management.

Adding Knowledge to Virtual Teams in the New Normal: From Leader-Team Communication towards the Satisfaction with Teamwork

The present paper sets out to investigate the relationships among several key constructs that cover the work patterns and processes in the context of the COVID-19 pandemic. Emphasis is laid on the leader-team communication, the fostering of a strong team culture, team performance and satisfaction with teamwork in the case of virtual teams. The scrutiny is intended to complement recent developments in the field which compared traditional and virtual teams at different levels by adding knowledge to virtual teams’ communication and interaction patterns and processes. In this vein, an online survey was conducted with 175 members from different virtual teams. The findings showed the advancement of a pertinent conceptual model, mostly displaying significant relationships among constructs. Four out of the five formulated hypotheses were validated, the highest influences being reported between leader-team communication and team culture, respectively, and between team performance and satisfaction with teamwork. Furthermore, the structural model explained over 50% of the variance in the satisfaction with teamwork, thus supporting the relevance of the inferred relationships.

Peer assessment after clinical exposure (PACE): an evaluation of structured peer support for staff in emergency care

BACKGROUND

There is an increasing body of evidence that identifies psychological stressors associated with working in emergency medicine. Peer Assessment After Clinical Exposure (PACE) is a structured programme designed to support staff following traumatic or chronic work-related stressful exposure. The first author of this study created the PACE programme and implemented it in one emergency department (ED).

AIM

A service evaluation designed to explore the thoughts and experiences of the staff who accessed the PACE support service.

METHOD

Participants were selected by a non-probability convenience strategy to represent the ED staff population. The study cohort ranged from junior staff nurse level to emergency consultant. Data were collected using a semi-structured interview and examined by the method of interpretative phenomenological analysis.

FINDINGS

This study confirmed the findings of previous research that current pressures within the ED include crowding, time pressure and working within an uncontrollable environment. Eight participants identified an absence of previous emotional support resulting in dissociation and avoidance behaviours following traumatic exposure. Overall, the PACE service was well received by the majority of staff (11/12). There was a positive association with the one-to-one element and the educational component helped to reduce the stigma associated with stress reactions after work-related exposure.

CONCLUSION

PACE received a positive response from staff. This service presently does not exist elsewhere in the NHS so further research will be needed to evaluate its long-term impact and effectiveness on a wider scale.

Retention of doctors in emergency medicine: a scoping review of the academic literature

INTRODUCTION

Workforce issues prevail across healthcare; in emergency medicine (EM), previous work improved retention, but the staffing problem changed rather than improved. More experienced doctors provide higher quality and more cost-effective care, and turnover of these physicians is expensive. Research focusing on staff retention is an urgent priority.

METHODS

This study is a scoping review of the academic literature relating to the retention of doctors in EM and describes current evidence about sustainable careers (focusing on factors influencing retention), as well as interventions to improve retention. The established and rigorous JBI scoping review methodology was followed. The data sources searched were MEDLINE, Embase, Cochrane, HMIC and PsycINFO, with papers published up to April 2020 included. Broad eligibility criteria were used to identify papers about retention or related terms, including turnover, sustainability, exodus, intention to quit and attrition, whose population included emergency physicians within the setting of the ED. Papers which solely measured the rate of one of these concepts were excluded.

RESULTS

Eighteen papers met the inclusion criteria. Multiple factors were identified as linked with retention, including perceptions about teamwork, excessive workloads, working conditions, errors, teaching and education, portfolio careers, physical and emotional strain, stress, burnout, debt, income, work-life balance and antisocial working patterns. Definitions of key terms were used inconsistently. No factors clearly dominated; studies of correlation between factors were common. There were minimal research reporting interventions.

CONCLUSION

Many factors have been linked to retention of doctors in EM, but the research lacks an appreciation of the complexity inherent in career decision-making. A broad approach, addressing multiple factors rather than focusing on single factors, may prove more informative.

Work-based strategies/interventions to ameliorate stressors and foster coping for clinical staff working in emergency departments: a scoping review of the literature

BACKGROUND

Exposure to occupational stressors is an issue for staff working in emergency departments, managers and health services. The aim of this review was to identify, map, and synthesise the range and scope of current evidence for work-based strategies or interventions used in emergency departments to reduce occupational stressors and/or improve staff coping.

METHODS

The framework proposed by Arksey and O'Malley guided this review. A search of CINAHL, MEDLINE, Scopus, Cochrane and PsycINFO databases from January 2007 to June 2019 was applied. A total of thirty-one articles were included in this review. Quality appraisal was undertaken.

RESULTS

Exposure to or impact of occupational stress and workplace violence were common foci. A range of outcomes (such as burnout levels, stress levels and quality of life) were measured in the included studies. All studies demonstrated some improvement in outcomes measured although most were evaluated for relatively short duration. Quality of evidence varied.

CONCLUSION

Strategies ranging from mindfulness to organisational redesign have been trialed to diminish stress and enhance coping of emergency department staff. Understanding the effectiveness of strategies is an important early step in improving the working environment for emergency department clinicians in an evidence-informed manner. Such information may be of use to managers to inform decision making regarding the most appropriate strategy to implement in their emergency department.

Core components of a staff wellness strategy in emergency departments: A clinician-informed nominal group study

OBJECTIVE

Busy, high-stress EDs prompt many work-based interventions to address staff wellness, with mixed success. The aim of the present study was to enable ED clinicians to systematically identify core components of a work-based strategy to improve their working environment and/or coping.

METHODS

Purposively sampled ED doctors and nurses from one health service were invited to participate in modified nominal group technique. Participants identified, from a pre-defined list, a key ED stressor and then discussed and ratified proposed core components of a work-based strategy to address or ameliorate this stressor.

RESULTS

Two nominal group technique sessions were held with a total of 10 participants (n = 7 nurses and n = 3 doctors). Participants proposed several strategies aimed at both individual and organisational levels to address occupational stress and coping, and support staff well-being in the workplace. These included mobile/web-based applications, group counselling sessions, yoga, social activities, team building activities and debriefing. Participants described three key components to promote staff wellness and hence enhance their ability to buffer negative aspects of occupational stress: (i) increased individual and team support; (ii) development of professional resilience; and (iii) maximising opportunities for social connection.

CONCLUSIONS

Ensuring appropriate systems, services and support for ED staff should be a priority at local departmental, wider organisational and governmental levels. ED clinicians are ideally placed to identify such systems, services and supports. Managers and policy makers can use these findings to inform the implementation of interventions in EDs.

Physicians' Perspectives About Burnout: a Systematic Review and Metasynthesis

BACKGROUND

Doctors' burnout is a major public health issue with important harmful effects on both the healthcare system and physicians' mental health. Qualitative studies are relevant in this context, focusing as they do on the views of the physicians of how they live and understand burnout in their own professional field.

OBJECTIVE

To explore physicians' perspectives on burnout by applying a metasynthesis approach, including a systematic literature review and analysis of the qualitative studies.

DATA SOURCES

Medline, PsycINFO, EMBASE, and SSCI from the earliest available date to June 2018 REVIEW METHODS: This metasynthesis follows thematic synthesis procedures. Four databases were systematically searched for qualitative studies reporting doctors' perspectives on burnout. Article quality was assessed with the Critical Appraisal Skills Program. Thematic analysis was used to identify key themes and synthesize them.

RESULTS

Thirty-three articles were included, covering data from more than 1589 medical doctors (68 residents and 1521 physicians). Two themes emerged from the analysis: (1) stress factors promoting burnout-ranked as organizational, then contextual and relational, and finally individual-factors and (2) protective factors, which were above all individual but also relational and organizational.

CONCLUSIONS

The individual and organizational levels are abundantly described in the literature, as risk factors and interventions. Our results show that doctors identify numerous organizational factors as originators of potential burnout, but envision protecting themselves individually. Relational factors, in a mediate position, should be addressed as an original axis of protection and intervention for battling doctors' burnout.