Challenging working conditions in health services, especially in emergency departments (ED), lead to high levels of stress and burnout. This contributes to the staff retention problem recognised by professional associations such as RCEM and ACEM. As well as being a practice and policy priority, there have been repeated calls for research to better understand the problem.
Most people working in ED have first-hand experience of the impact of working somewhere short-staffed or with a high staff turnover. It is harder to deliver quality care and often a sign that something isn’t right with a department. A scoping review of retention in ED showed several factors associated with retention, but these studies don’t say what is most important or why.
Image adapted from: Darbyshire D, Brewster L, Isba R, Body R, Basit U, Goodwin D. Retention of doctors in emergency medicine: a scoping review of the academic literature. Emerg Med J. 2021 Sep;38(9):663-672. doi: 10.1136/emermed-2020-210450. Epub 2021 Jun 3. PMID: 34083428; PMCID: PMC8380914.
What were the aims of the study?
The study focused on three main aims.
Understand the day-to-day lived experience of EM doctors to identify and explore factors influencing retention.
Situate these descriptions within the current educational and health policy contexts.
Advance the debate, make policy, and practice recommendations based on a detailed understanding of the retention of medical staff in emergency medicine.
What did they do?
The study was an ethnography (a research method that involves embedding researchers in the study environment). Researchers spent ~132 hours observing practice in a UK emergency department and making notes about what they saw.
The observations were complemented by interviews with 41 participants, comprising 21 emergency physicians across two sites, ten former emergency physicians, and ten people from organisations interested in staff retention in emergency medicine and healthcare.
This led to a huge body of written data to which previous literature was added. The authors analysed the data using reflexive thematic analysis. This helps the researcher identify and analyse patterns in data.
What were the results?
Portfolio careers
The good news for Don’t Forget the Bubbles readers is that a bit of Paediatric EM is a retention strategy for emergency physicians. But, it is not the PEM alone; it is the variety and the portfolio career. This is something we see elsewhere in medicine as well. Those with more diverse careers are more satisfied and work more sustainable.
Working patterns
Less than full-time working (in the UK for doctors, full-time is 40 to 48 hours per week) is the norm for emergency medicine trainees in the UK and is increasingly common across healthcare. What this says about the nature of full-time work is a question for another day. But for now, consider thinking about less than full-time working as a retention strategy rather than just a reactive necessity to burnout. Self-rostering and annualisation help facilitate less than full-time working and portfolio careers and can help those working full-time.
Education and retention
The importance of education for patient care is irreplaceable. It is also important for staff as it provides enjoyment and variety in the working day for the educator, and it demonstrates to the learner that they are valued, both of which help retention.
The emergency department, or any workplace for that matter, can be a supportive community that helps retain employees despite the challenges inherent to the work or workplace. We often consider community (or team building) as big events such as away days or social events. However, community is also built by repeated brief interpersonal interactions between workers. Think of the conversation you have in snippets across three days at work. It’s things like this, repeated over time, which build trust and relationships and, ultimately a community. The cohesion between the people we work with is essential for retention.
The workplace
As we know, the working environment is a challenge and emergency physicians develop workarounds. These are often low-key, such as using a stethoscope when you can’t find a tendon hammer. Corridor care could also be thought of as a workaround. These are necessary to function but are a sign of a significantly stretched service.
Get a mentor
As a final point, mentors can be really helpful for developing a sustainable career and if you don’t have one think about getting one. Many departments, regions and training programmes offer schemes, or you can just ask around.
Take home message
References
Darbyshire, D., Brewster, L., Isba, R., Body, R. and Goodwin, D., 2024. Retaining doctors in emergency medicine: an ethnographic study of emergency departments in England. BMJ open, 14(9), p.e086733.