Estimated reading time: 9 minutes
One of the things that Iain and I have discussed on the podcast recently is the concept of maintaining a balance in tough times. There is no doubt that at the moment work is tough. The number and complexity of patients attending emergency departments is unprecedented and there are a number of other associated challenges. I could name many, but the lack of support from the wider system, both in concentrating the risk in emergency departments and the feeling that we are individually responsible for the poor care that some patients receive is really challenging and I know that it has led to a number of people leaving the profession (all professions, but arguably nurses more than doctors). In particular, our ability to do the job at the level that we aspire to puts us all at risk of moral injury and I’m seeing that too.
This post is not about reducing the pressure, although that is something that we should be working on (of course). This post is a reflection on how we might provide some balance in our work, and a real plea for us to think about the balance that has always existed in our practice, but which is more stressed than ever at the moment. It is a challenge, particularly to leaders and managers to take a step back and look at some of the issues that we all face and how we might actively support, and in some cases inadvertently worsen the balance of working in EM.
What do we mean by balance in this post?
There are lots of balances that we live with. Balances between work and home life are well described, although for many of us who socialise with work colleagues and take/think about work at home it’s arguably more of a blend (and that’s fine). In this post I want to focus on those activities that we undertake at work and how there are balancing factors between what we gain energy from at work and what drains our energy. Let’s face it, not everyone loves every minute of every day at work (Ed – answering complaints about the contents of the vending machines for example).
So there will be variation but for many of us, the positive factors are those where there is often an element of associated discretionary effort and this is key. Some examples from a past age, based on my view of the world (yours will be different) are below.
|Topic||Positive/Negative||Impact on me|
|Shop floor teaching||Positive||+++|
|Managing an unsafe department||Negative||– –|
|Challenging speciality interactions||Negative||–|
|Reviewing ward based patients*||Negative||–|
|Writing pointless reports||Negative||– – –|
|Mandatory training on topics that I never do||Negative||–|
|Patients coming to harm because of crowding||Negative||– – – – – – – –|
* not the patients themselves as that’s often great. Rather, as an example a system that spreads them across multiple wards and often involves referring the patient back to the specialty that should have accepted them at first, but who had initially declined (often due to bed pressures).
So we end up with something of a balance with different factors affecting the experience of working in emergency medicine. How that balance works for you, and what factors exist on your particular balance will vary. For me, the positives are strongly associated with research and teaching which I hope is no surprise, but for others it may be management roles, clinical excellence or other aspects of what we do.
Our great colleague Liz Crowe recently reminded me that these pressures and preferences so to some extent that aspect is not new. However, in the modern world there is less ebb and flow between them as we have come busier. We also seem to have less ‘down time’ than we used to which was an opportunity to rebalance. These factors combine to make us think that we may need to actively manage our experiences rather than leave them to chance.
Maybe now is a good time to think about what your balance looks like and what factors affect it.
|Topic||Positive/Negative||Impact on you|
Once you’ve done that it’s worth considering the difference between positive and negative factors. In nearly all cases the negative factors will be ones that you are not really in control of. They are typically tasks that are a requirement of you, or are set by other people. It’s unlikely that you put a lot of discretionary effort into them. In contrast those factors that are positives are those that attract any discretionary effort that you may have.
What happens to your balance under pressure?
My observation and experience has been that when departments are under stress then those aspects of our work that attract discretionary effort, notably teaching, research, development, CPD are challenged as not being ‘core’ business. To some extent I can see why this might happen. Faced with a department full of patients, long waits and clinical risk it would seem reasonable to some that cancelling teaching, CPD, not recruiting would be the right thing to do. It’s what we would do in a major incident and I don’t think any of us would have an issue with that.
However, our current problems are persistent and sadly a new normal. The numbers of patients in our departments are consistently at high levels and there is not an ebb and flow of work intensity. For many emergency departments there is a constant pattern of workload exceeding capacity. If this is not understood, or if decisions are made on short time horizons then it is logical to stop doing any development or patient safety work, sacrificing this to solve the queue at that particular moment in time, but it is short sighted and counterproductive.
Emergency departments have typically thrived and attracted staff because of the opportunities for learning and development that exist within them. Our speciality has always attracted problem solvers, teachers, learners and researchers (or at least the deeply curious), and that is something that we need to nurture, develop and celebrate. In the current climate that is increasingly challenged by the workload and the reaction of organisations to that increased workload.
My belief is that by reducing the opportunities for the balancing factors that allow us to have a successful and fulfilling career will rapidly increase the likelihood of burnout, or leaving the speciality through retirement or alternative careers.
As individuals and leaders we must therefore examine what the balancing factors are and how they might be developed to provide meaningful careers. Instead of assuming that clinician’s experience will be balanced by the natural ebb and flow of intensity (which we have lost) it’s important that leaders seek out, defend and advocate for balancing factors. If. you’re in a leadership position may ask yourself where you stand on this (and to quote the Suffragette’s, I’m talking about deeds not words).
What do we do about it?
You have arranged simulation teaching on a Thursday morning. It is typically attended by those clinicians on STAR days (Supervision, Teaching, Audit, Research) plus a few clinicians from the clinical shift. The rota-master usually allocated an additional two docs for that day to allow this.
On this particular day there is a long wait to be seen, as there is every single day at the moment. The wait is long (>4 hours), but typical for every day in the last month.
A senior manager attends and tells you to cancel the session so that all clinicians can try and get the wait down. They are in the department and can be put to work straight away.
What do you do?
If you haven’t already, go back to the table above and list the main balancing factors in your work life. Then, if you are in a position of leadership think about how the balance looks for those that you lead (Ed – crazy idea, why not ask them!).
What is it at work that brings you joy and satisfaction and what is it that drains you? In very simple terms think about adding to the positives and subtracting the negatives. As a leader then think about how you protect those positives for yourself and for others and do not fall into the trap of going for short term gains in order to tackle unachievable targets at the expense of medium and long term clinician support. This is something we see all too often and it is demoralising, and almost certainly leads to problems with recruitment and especially retention. As a consultant, associate specialist or staff grade in a UK emergency department it’s likely that you will be the longest serving group, as managers and to a lesser extent nurses are more likely to rotate into other jobs (Ed – note that ANPs are now also becoming similarly ‘sticky’ in many places). It is arguably easier for those who have a long term investment in a department to ensure that long term development is not sacrificed at the expense of chasing short term, often unachievable, targets. Maintaining that long term view will be difficult at times and will almost inevitably lead to the occasional difficult conversation. See this post for the challenges that face every manager/clinician in EM.
In order to reset our balance we can either do less of the stuff that drains us, or more of the stuff that inspires us. What we must try and avoid at times of pressure is do less of the stuff that we enjoy and which inspires us. Think about your balance and how it’s been changed in recent years. How can you offload the negative and increase the positive elements of your work load? I know many consultants have changed job plans to achieve this and we are seeing more doctors in training working less than full time and developing their own portfolio careers. I think this is something that we should strongly support as colleagues, departments, hospitals and colleges.
No matter what your occupation there will always be things about work that are challenging and irritating. In healthcare today we need to pause and savour the things that are positive. We must also help ourselves, and our colleagues manage, confine and have some agency over those that do not.
Note: I am very aware that some people will find themselves feeling trapped and feeling unable to make the suggestions above happen. I totally get that, but if that is the case please do think about getting advice, coaching, support from other sources. There are always options and support out there if you know where to look for it, and we are happy to signpost.