JC: Retention, working conditions and opportunities in EM

Estimated reading time: 9 minutes

This week we look at a paper from the EMJ that explores what are that main factors influencing retention, working conditions and opportunties in UK emergency medicine. This is timely as there is no doubt that there are many EM clinicians who are facing a great deal of work related stress at the moment. We see this though issues with retention, emigration and in formal and informal feedback mechanisms. If you have any doubt about about this, then a short trip around twitter and other social media platforms will reinforce this view. That said, the UK EM experience is not universally bad, and some units do great work. Understanding that variation and the pressures that staff experience is surely an important step on our path to improvement.

This week’s paper is published in the EMJ​1​ and the abstract is below. As always we recommend that you read the whole paper and come to your own conclusions.

The Abstract

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.

Daniels J, Robinson E, Jenkinson E, et al
Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study
Emergency Medicine Journal 2024;41:257-265.​1​

What kind of paper is this?

This is a qualitative paper that explores the opinions and beliefs of a range of EM staff on working conditions in EM. Qualitative papers are good at explaining the ‘why’ of an issue as opposed to simply the ‘what’. In this case we know that there are issues with retention and working conditions, and no doubt we all have opinions on why they are there, but this sort of approach is a way of systematically looking at emergency clinicians views in order to look for and develop themes that can then inform future practice.

There are many different types of qualitative methods, and so we also need to consider the researcher’s approach and choice. In this case the researchers used online focus groups to gather data and then a directive content analysis of that data. That means that the researchers started with some idea of what the issues are, and then used the focus group data and analysis to delve deeper and to understand them better. In other words it’s not a complete free for all in the focus groups, which aids focus on the main issues as the researchers see them, but this may miss some data that was not apparent (though in truth we often find people talk around a subject even with a semi-structure approach).

Who was studied?

Participants were recruited through online advert and RCEM communications. Another way of putting this is that clinicians heard about the study and volunteered to take part. Although this is common way of attracting participants to interview and group based studies, it does run the risk that respondents/volunteers are not typical or representative of the wider population (though this is less of a worry in qualitative studies where the subsequent generalisability of results is often not an aim). Snowball recruitment, where one participant encourages another was also used.

Doctors, nurses and ACPs were eligible.

116 people expressed an interest in participation, but after exclusions and availability restrictions just 33 were interviewed. Whilst this may seem a small sample in quantitative studies, it’s arguably quite a large sample for this methodology. That said, it is unclear from the paper whether the sample size was predetermined, determined by the methodology, or opportune.

What did they do?

The focus groups were directed using a semi-structured guide of questions. This is common in studies of this type. The meetings were recorded, transcribed and then analysed for themes by two researchers.

What did they find?

As always, read the full paper yourself, but the headline data is the finding of four themes. In fact there is far too much data in the paper to summarise here, as the power of the data is in the quotes and explanations from the participants across the four themes and I recommend that you read these. Many of them will be very familiar to our readers, and I personally recognise many of them.

  1. Untenable work environments
  2. Culture of blame and negativity (the most difficult part of the job)
  3. Striving for support
  4. Compromised Leadership

Within the narratives, and as explained in the infographic below we see that many of the concerns are inter-related and amplifying.

The authors draw particular attention to the issues of leadership in the ED, perhaps because it is perceived as a modifiable and trainable element. It is perhaps also the path to influencing the other factors which are often out of the ED’s control, but within our sphere of influence. I initially struggled to see from the paper why this was chosen as the lead factor/finding to take forward from the results, but I have clarified this and it is described in the paper as the unifying and modifiable theme that runs across all the issues identified by participants. This is further expanded in table 2 which provides a number of suggested solutions to the problems described by the participants. I’ve clarified that both the issues/themes and proposed solutions were created by the participants and linked the authors. It is noteworthy that RCEM has (rightly) promoted leadership training as a key skill for emergency clinicians and this paper supports that view. After reading this paper I would recommend reading the PIPP recommendations (Psychologically Informed Practice and Policy). It is also reassuring that the suggestions in this paper broadly concur with the RCEM leadership training and PIPP recommendations.

The authors conclude with a number of recommendations to improve clinical leadership, including time. courses and external support. All of these make sense, though like any intervention the impact of those recommendations (if adopted) should themselves be evaluated.

We must also be mindful of the wide range of what is considered to be leadership. When I think of leadership it extends from small teams e.g. trauma teams, through to shifts, the department, the trust business group, division etc. etc. Similarly there are subdivisions of leadership in specialist areas such as education, frailty etc. The implication being that leadership roles are really widespread and varied within the emergency department workforce. The authors recommend that all clinicians in training should be exposed to leadership training and that’s something we would endorse here at St Emlyn’s. In the paper there are understandable recommendations to engage with the RCEM leadership programs, although these have predominantly been aimed at doctors in traditional training programs. However, they are arguably as relevant to other professional groups within and external to the emergency department and we would recommend them to other groups too.

The key message for me, and something I’ll be developing at a college meeting next week is that there are aspects of leadership and support that can make a difference to the working lives of our colleagues. Although there are many external stressors on the emergency department/speciality there are aspects that we can work on to strengthen the balancing factors that might just lead to a better working experience for us all. I would recommend a read of table 2 for ideas on how this might work for you.

Please have a read of the full paper and consider whether the findings here might relate to your department.

Final thoughts

This paper reinforces my belief that emergency medicine is under strain and that there are common themes across professional groups as to why this may be. It does help me understand a little more about how we might influence that within departments through education, training and development and I do like the reminder to check out the RCEM learning materials for further learning and development.

COI: As dean of RCEM at the time of publication I am likely to look more favourbly on RCEM sponsored studies and recommendations.



  1. 1.
    Daniels J, Robinson E, Jenkinson E, Carlton E. Perceived barriers and opportunities to improve working conditions and staff retention in emergency departments: a qualitative study. Emerg Med J. Published online January 9, 2024:257-265. doi:10.1136/emermed-2023-213189

Further Reading

  1. Daniels J, Robinson E, Jenkinson E, et al. Psychologically informed practice and policy (PiPP) project: study recommendations. Royal College of Emergency Medicine; 2023. Available: https://rcem.ac.uk/psychologically-informed-practice-and-policy-pipp/
  2. RCEM. EM leaders program. https://rcem.ac.uk/em-leaders-programme/
  3. RCEM. The impact of staff burnout and how to improve retention. DOI: 10.13140/RG.2.2.34376.90888

Cite this article as: Simon Carley, "JC: Retention, working conditions and opportunities in EM," in St.Emlyn's, January 17, 2024, https://www.stemlynsblog.org/jc-retention-working-conditions-and-opportunities-in-em-st-emlyns/.

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