Aims/Objectives/Background This study aims to understand how emergency physicians work sustainably in an increasingly challenging environment in the context of a retention crisis across all grades of emergency physician.

Senior clinicians provide better care in the emergency department; performing fewer unnecessary investigations, receiving fewer complaints and making fewer errors. Seniority is dependent on retention. Exodus from training and consultant grades is expensive.

The problems of staffing an emergency department has not been previously addressed by focusing on how those who work in them manage to do so.

Methods/Design Ethnography conducted at a UK emergency department for 12-weeks, totalling nearly 200-hours of observation. A second site was planned but not possible due to COVID-19.

Interviews with emergency physicians of all grades from the two initially planned sites, with doctors who have left emergency medicine, and with individuals working for stakeholder organisations. 40 interviews in total, averaging 45 minutes.

Systematic scoping review of the relevant academic and policy literature.

Reflexive thematic analysis of the ethnographic field notes, interview transcripts and literature.

Results/Conclusions Emergency physicians are active in managing their working day to mitigate the labour and environment. These actions have multiple overlapping motives but are demonstrably forms of retention work. They utilise objects and the environment in creative ways (materialities), for example completing paperwork in the resuscitation room because it is calm and air-conditioned.

They utilise humour in a primarily self-deprecating manner and prioritise education as a means of valuing other staff and creating variety in their workday. Emergency physicians describe teamwork as vital to retention, but this is disparate and developed over long periods of time and therefore better described as community.

The principle sustainability strategies employed limit exposure to shop floor working. This is achieved through less-than-full-time working and portfolio careers. These strategies predate policy which describes them in terms of flexible working.