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‘Strong leadership’ key to tackling poor A&E working practices

More support for senior nurses and other clinical leaders in accident and emergency care is needed in order to lift staff retention out of “crisis levels” and tackle myriad problems, suggest a UK study.

Among a range of issues, NHS nurses told researchers they experienced unrealistic expectations from patients, wards that were unfit for purpose and unsupportive cultures that negatively affected wellbeing.

“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”

Anonymous nurse

Meanwhile, the researchers found clinical leaders – identified as best placed to lead change – were not given the necessary time, space or resources to improve their departments in any of the problem areas.

The study was carried out by researchers from the University of Bath, University of Bristol, University of the West of England and North Bristol NHS Trust.

Published in the Emergency Medicine Journal (EMJ) today, their findings were based on focus groups with around 30 nurses, doctors and advanced care practitioners working in emergency departments.

Researchers sought to identify barriers and solutions to improving staff retention at a time when, they said, emergency care was seeing a rise in demand due to both sheer numbers of patients and acuity.

Four key areas were identified as issues negatively impacting on retention: a ‘culture of blame and negativity’, ‘untenable work environments’, ‘compromised leadership’ and ‘striving for support’.

On the first area, survey participants told researchers they felt their work culture was unsupportive, in some cases describing it as “toxic” and that it had a “marked effect” on their wellbeing.

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However, management was unsympathetic and there was anxiety over how clinicians may be perceived if things went wrong, according to nurses and doctors who took part in the focus groups.

An advanced care practitioner said: “You worry about making a mistake, and if you did make a mistake who would have your back.”

A nurse described a “classic example”, where a senior member of the team who “really knows her job” was “quite critical really, in a very negative way” about colleagues had managed their patient.

Meanwhile, a doctor said it felt like there was an expectation that clinicians should be “unbreakable” even under the worst strain, and it was unclear who among leaders to approach if they had a problem.

The second area, ‘untenable work environments’, referred to the physical and mental space in which emergency care clinicians worked.

Both doctors and nurses reported frustration at poor, inadequate or even missing facilities.

These included a lack of suitable toilets, lockers and changing rooms, hot food only being available at certain times, poor-quality IT systems and rest spaces which are too far away from the workplace.

One clinician who took part in the study reported having to share toilets with patients. This kind of issue varied from place-to-place, however.

One nurse told researchers: “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.”

The same nurse described wards as “unfit for purpose”, and pointed the finger at trust leaders who were unaware of what needed fixing, replacing and improving.

As well as the issues with their practical working environment, the researchers heard evidence from nurses about the psychological one in which they worked.

“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,” said one nurse, referring to the intense demands and seeming lack of improvements being made.

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Meanwhile, a doctor compared working in emergency care at present to being at war, and said the long shifts and intensity meant staff needed recovery times just to avoid burnout.

‘Striving for support’ referred to the feeling that there were barriers to accessing wellbeing support, noted the researchers.

Common themes among participants were that support services were often only accessible during time off, they were “geared to a 9-5 non-clinical workforce” and there was an expectation that people kept mental health difficulties to themselves.

One nurse said: “I think for me it still feels like a bit of a stigma about saying I am struggling what should I do next.”

Another said there was a lack of a clear pathway for where to access help . Many clinicians told researchers they knew what support was available, but did not know when it was open, where it was based or who could access it.

The study authors said: “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.”

The final category in the study, ‘compromised leadership’, was identified as an underlying cause for the other areas of improvement.

Clinical leaders, the researchers found, were in theory well placed to lead by example and improve workplace culture and were described as a “key conduit for change”.

However, such leaders told the researchers that they felt “poorly supported” and were not given protected time to work on their non-clinical leadership skills.

One emergency care clinical leader said: “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.”

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A nurse, who also has a leadership role in an emergency department, said: “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.”

“In particular, strong leadership emerged as a key driver of change across all aspects of working practices,” noted the study.

Chief among the study’s recommendations for NHS England was ensuring leadership skills were given early on in clinical training and that clinical leaders had protected time to deliver their roles effectively and drive change.

It also stated that a “clear pathway” for emergency care clinical leaders to address upper NHS trust management would be essential to improving the wellbeing and environment of the departments, and in turn the retention of staff.

Tailored training, the researchers said, was needed to make sure leaders can put in measures to improve retention, given the additional strains on emergency departments.

Lead study author Dr Jo Daniels, from the University of Bath, said: “A common thread that emerged across our interviews was the critical importance of leadership in hospitals.

“Those in leadership positions are powerful agents of change, and have pivotal influence over team functioning, staff wellbeing and patient outcomes.

“However, lines of accountability and communication with executive management needs to be clarified, opened up and improved.”

Dr Daniels added: “A new focus on leadership training and ongoing support for those in leadership roles will be critical to this.

“Given its central importance and the scope for leadership improving wellbeing at work, we have a prime opportunity now to address the problems which force staff to leave the workforce. Harnessing the potential in our leaders is where our focus should now lie.”

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