Morale: a theme of the moment.

The ED workforce ideas conference in Birmingham highlighted challenges, presented solutions and generated ideas; many of which were shared and discussed on Twitter.

One of these themes was on staff morale: a problem faced by many Emergency Departments. This has a knock-on effect with difficulties in retaining staff, including senior staff who have extensive experience of working in an ED.

As a doctor in one of the busiest EDs in the UK, staff happiness is very relevant, as it is essential to compensate for the intensity and volume of the workload. Therefore it was interesting to listen to Dr Rob Galloway talk about his ED at Brighton and Sussex University Hospitals; a department that tries to focus on letting its medical staff have a better work-life balance. This is partly done by allowing self-rostering for several levels of staff.

It has been introduced for senior nurses working in the Leicester Royal Infirmary (LRI), which has helped our staff retention. Another strategy used by Dr Galloway was to get foundation doctors interested in EM as a career by introducing several fellowships for post FY2 doctors, including educational posts.

The level of “brain drain” facing most Emergency Departments—due to poor staff retention—concerns me. From a service point of view: losing well trained senior staff has a knock-on effect to patient experience in the ED. Normally they would be replaced by staff who require time to be trained. Not only to work safely in an ED, but to adapt to changes from working on a ward versus ED. With this loss of experience, the amount of patients seen in the department (our effective processing power) goes down, and in return the wait increases. In other words: our efficiency decreases.

7 of the top 15 tweets were about staff and patient satisfaction

This is not the fault of new starters. It is well appreciated (and expected) that more experienced specialty trainees can see more patients per hour than specialty trainees in their initial years (ST1-2). However a turnover that is greater than the expected churn due to training pathways does cause problems. This was shown in a study completed by QMC and presented by Mr James Pratt. [Fig.1]

Fig. 1: Screenshot from #EDworkforceideas YouTube live stream

Senior doctors are key to chasing plans from core and foundation trainees, as well as making sure the plans are appropriate for the patients. Having a cadre of senior doctors helps to deal with those complex patients that present at all hours, and who may pull multiple staff members off the shop floor for long periods of time to ensure they are safe.

In my humble opinion, I worry staff happiness will have an impact on patient satisfaction, if it hasn’t already. Currently, departments are busier than I have ever seen–albeit during my short career in EM–and not getting any better. All NHS staff work incredibly hard, and everyone will no doubt have stories of staff they have worked with who have gone that extra mile, when it would have been easier to pick the path of least resistance. We do this job to help others. And while recognition for that is nice, it is certainly not my own, nor most of my colleagues' driving force.

With the sad reality that breaches will occur due to a multitude of problems (most of which are out of control of the staff in the ED) maybe it is time for some of the focus to move away from breaches and onto patient experience. We all know that an ED is a bright, loud, noisy and scary place to be for some people, especially older patients with cognitive impairment. While we have little control on the noise in the department, we can spend that extra minute being a good human to another individual who is scared and confused.

We need an increased focus on improving staff happiness through self-rostering for more staff groups; and helping staff have a better work-life balance – so we can retain our staff. These staff can not only do the job well, but also know the system we work in, which can only be good for patients. Tired staff with low morale will struggle to go that extra mile as often as they would like to.

This year I am working as an education fellow, so is there something I can do to help my colleagues? Education isn’t just about getting the best out of the work force, but also about people getting the best out of the experience. Like many departments, we have an in situ simulation program that we use to teach the ED team in difficult scenarios. Whilst it's clearly useful as a means to demonstrate the “optimal” way to approach a problem (and correct any common mistakes) I feel it is also an excellent platform to highlight and commend teams and individuals on excellent patient-centred care.

At the Leicester Royal Infirmary, we have developed an online form for acknowledging great care, called #GREATix. It is run alongside the traditional Datix system, but only to raise awareness of when things go well for patients.

Having education fellows on the shop floor means we are available for any member of the team to ask us about areas they need clarification on, regardless of grade or role. Foundation and core trainees often feel it is difficult to complete assessments due to workload, as do our advanced care practitioners, so being available to observe and complete assessments for this staff group improves their training, whilst allowing those on a clinical shift to focus more on patient care.

A major gripe trainees have is 'not being trained', so maintaining a regular presence in the department with the sole aim of training our trainees will hopeful help raise morale.

Do people quit working in the ED because they stop caring or because they stop being able to care in the way feel they should?
Edit & Peer Review by Damian Roland