Call to improve retention of A&E doctors with better working conditions

The working environment must be improved to improve the retention of A&E doctors, according to the first ever study of why emergency doctors stay - rather than why they leave.

The study in the BMJ Open entitled “How do we retain doctors in emergency medicine?” is by Dr Dan Darbyshire from Lancaster University Medical School, who is himself an emergency doctor.

He said: “The findings suggest that the working environment is a threat to retention—it needs improving. Retention is important as more experienced and senior doctors perform fewer unnecessary tests, make better decisions, and get fewer complaints. High turnover is correlated with poor organisational performance.”

Staff retention is a particular challenge in emergency medicine, with a 2021 workforce survey by The Royal College of Emergency Medicine revealing that :

• 50% of staff were considering reducing their working hours
• 26% were considering taking a career break or sabbatical
• 32% said this was due to workload pressures and 35% said this was due to burnout
• 69% of Clinical Leads revealed that locums were being used to fill permanent posts
• 22% of consultants were considering retiring early
• There was a shortfall of 2,000-2,500 A&E consultants in the UK in 2021

Dr Darbyshire spent over 132 hours of observations over 11 weeks in a UK hospital emergency department including 41 interviews with doctors.

Staff members complained the emergency department was often loud, “windowless but bright”, and invariably either too hot or too cold.

One interview participant described how the environment “could quite easily become a source of frustration that would make me not want to come into work”. There was “no staff toilet”, no changing room – “that's where I get changed, in the storeroom”.

All these frustrations were worsened by overcrowding.

One doctor said: “One of the things I [would] try [was] getting some headspace, so if it all got a bit too much I would go to a quieter part of the department, so maybe go sit in the seminar room and write in there for 10 minutes, or in resus if it wasn't a bomb site.”

Missing or misfunctioning equipment was a source of frustration and staff found it inconvenient and embarrassing to take a piece of equipment to a patient only for it to fail to work. Staff improvised, with for example, a doctor using a stethoscope to test reflexes as they could not find a tendon hammer.

Dr Darbyshire said: “Many things would have to change for the clinical space in the emergency department to improve. Crowding, exit-block, hospital-wide capacity problems, and difficulty accessing social care in the community are problems beyond the power of an individual department or even the specialty to resolve. Individual emergency departments can improve aspects that are within their control. Adequate break facilities, a changing room and a staff toilet, spaces for education and handover that are fit-for-purpose, are all achievable and would impact the workplace experience. “

The study looked at strategies employed by doctors to keep working in A&E despite the pressures.  These included education, with senior staff prioritising the education of more junior staff.

Dr Darbyshire said: “The junior doctors in our study were made to feel that their learning was important to the team by the actions of those leading the team. The value placed on their education as an intrinsic part of their work created space to develop in the emergency department, and they felt this fostered sustainability in their careers. Likewise, for the consultants, these elements of education enriched their interactions with trainees and made a qualitative difference to their daily working lives.”

Community was also important, creating by brief interpersonal interactions between emergency department workers.  

One doctor said: “So, I think in terms of the department we are quite a tight knit group, there is a lot of human interaction with the team as well, which I quite enjoy, and I'd say so yeah, that's kept me going.”

Other retention strategies included portfolio careers rather than full-time working as well as self-rostering.  Participants reported that a good rota helped retention and a bad one hindered it while both annualisation and self-rostering enabled staff to plan essential parts of their lives such as childcare and family holidays, respond to unexpected events, and meet training requirements.

Another strategy was mentorship which provided a way to managing the demands of a career in emergency medicine long term.

Dr Darbyshire said: “This paper shows that it is not enough to fund initiatives to encourage people to join the specialty; it is also vital to understand what makes them stay to ensure that investment in the clinical workforce is sustained over time. “

The research was co-authored by Dr Liz Brewster, Professor Rachel Isba and Dr Dawn Goodwin from Lancaster University Medical School and Professor Richard Body from the University of Manchester.