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Abstract
Objective To explore the experience of psychological distress and well-being in emergency medicine (EM) consultants.
Methods A qualitative, interpretative phenomenological analysis (IPA) study based on 1:1 semistructured interviews with EM consultants working full time in EDs across South West England. Eighteen EM consultants were interviewed across five EDs, the mean (SD) age of participants being 43.17 (5.8) years. The personal meanings that participants attached to their experiences were inductively analysed.
Results The analysis formed three superordinate themes: systemic pressures, physical and mental strain and managing the challenges. Pressures within the ED and healthcare system contributed to participants feeling undervalued and unsatisfied when working in an increasingly uncontrollable environment. Participants described working intensely to meet systemic demands, which inadvertently contributed to a diminishing sense of achievement and self-worth. Consultants perceived their experience of physical and emotional strain as unsustainable, as it negatively impacted; functioning at work, relationships, personal well-being and the EM profession. Participants described how sustainability as an EM consultant could be promoted by social support from consultant colleagues and the ED team, and the opportunity to develop new roles and support ED problem solving at an organisational level. These processes supported a stigma-reducing means of promoting psychological well-being.
Conclusions EM consultants experience considerable physical and mental strain. This strain is dynamically related to consultants' experiences of diminishing self-worth and satisfaction, alongside current sociopolitical demands on EM services. Recognising the psychological experiences and needs of EM consultants and promoting a sustainable EM consultant role could benefit individual psychological well-being and the delivery of emergency care.
- emergency care systems, emergency departments
- emergency department
- psychology, staff support
- qualitative research
- staff support
Statistics from Altmetric.com
- emergency care systems, emergency departments
- emergency department
- psychology, staff support
- qualitative research
- staff support
Key messages
What is already known on this subject?
27–51% of ED doctors meet threshold for minor psychiatric illness; the statistics for ED consultants can be as high as 44%, a higher proportion than found in the general population and doctors in other specialties.
These levels of psychological ill-health carry significant risks to patient care, the health of the organisation and individual mental health. Research using descriptive statistics has established the profile of psychological distress in this population, but the extent to which this can support interventions is limited. Research has lacked the application of theoretical models, and a better understanding of the processes related to the reported levels of psychological distress is needed.
What this study adds?
This qualitative study of emergency medicine (EM) consultants shows that psychological stress is related to diminishing self-worth and satisfaction, and rising demands on EM services. This places EM consultants at risk of failing to sustain job performance, functional levels of mental and physical health, and career longevity. Social and psychological theory can be used to explain these findings and inform supportive and preventative measures that can be implemented at the organisational and individual level.
Introduction
Providing safe and effective services delivered by trained emergency physicians is at the centre of emergency care in any national health system. There are increasing pressures being placed upon developed and developing systems worldwide that compromise the delivery of basic care and cost-effective standards, even in well-resourced systems.1 Growing workloads in EDs are contributing to intolerable working environments for senior physicians, who are experiencing significant strain, a pattern that can be seen in EDs across the globe.
Emergency medicine (EM) consultants work with a number of changing stressors; unpredictable workloads, high patient attendances, limited resources, repeated exposure to traumatic events, potentially violent situations, target-driven practices and penalties, fear of malpractice lawsuits or complaints, repeated interruptions and critical decision making (often based on incomplete information).2 ,3 In 2015, the proportion of patients in the UK that spent more than 4 hours in the ED reached its highest level in over a decade; the national target being 95% of patients should spend no longer than 4 hours in A&E, with each breached target incurring financial penalty for the local health provider.4 Unsustainable workloads and insufficient numbers of senior EM physicians is an issue for EDs internationally. Research emerging from the USA and Europe indicate that this strain has an additional impact on physicians training in the ED, contributing to negative experiences and influencing their upcoming career choices and subsequently the future of the specialty.5–7
Psychological distress among physicians in highly demanding specialties is well documented and carries significant risks to patient care, the functioning of the organisation and individual mental health. In the UK, emergency physicians, but not other ED staff, have been found to be at increased risk of psychological distress.8 A postal survey of ED consultants found that 44.4% (154) had GHQ-12 (General Health Questionnaire-12) scores over the threshold for psychological distress, compared with 17.8% found within the general population and 21–27% for consultants in other specialties.9–11 In the same survey of ED consultants, depression was found in 18% (63) and almost 1 in 10 (34) reported suicidal ideation.9
Research from the USA suggests that contributing factors to poor EM physician well-being are high patient loads, high patient mortality, peer competition, long hours and sleep deprivation.12 In France, physician burnout and low-quality teamwork has been found to be significantly associated with intent to leave the profession.7 In the UK, positive psychological health in EM physicians has been associated with problem-focused coping styles (eg, planning) and higher levels of perceived social support at work.8
Statistical associations between stressors of the ED environment, working relationships and limited personal and professional resources are well documented in the aforementioned literature (see ‘key message’ section). However, an in-depth understanding of the processes that underlie these stressors and associated psychological distress is yet to be investigated. The application of psychological theory to develop our understanding of these processes and inform interventions is also lacking. In order to improve the well-being of EM consultants, maintain high-quality patient care and promote career longevity, a detailed understanding is needed of how EM consultants experience their role and working environment, and how it relates to their experience of stress.
The following questions were investigated in this study:
How do EM consultants perceive their psychological health and well-being?
What challenges do EM consultants face and how do these influence their psychological health?
How do they cope with these challenges and what is the impact of these coping responses?
Methods
Design
An inductive, contextual qualitative research design based on interpretative phenomenological analysis (IPA)13 was employed, using 1:1 semistructured interviews. IPA is an approach that aims to understand how a given person (EM physician), in a given context (working as consultant in an ED), makes sense of a given phenomenon (their perceived psychological health). The aim is to gain knowledge of how participants make sense of their experiences; revealing rich, detailed and personal insights, not captured by other research designs.
Participants
All physicians working at consultant level in selected EDs across the South West region of the UK were invited to take part using purposive sampling techniques. Of the 19 type 1 EDs (a consultant led 24-hour service with full resuscitation facilities and designated accommodation for the reception of emergency patients) in this area, five EDs were chosen to recruit participants due to homogeneity of the sites. The estimated total patient attendances for the year 2011, across the five sites, were 321 000; the average attendance per site being 64 000 (minimum 42 000 and maximum 90 000). At each ED site, the lead EM consultant agreed to distribute information about the study (using an approved patient information sheet). All consultants who registered their interest in the study were contacted directly by the researcher to ascertain whether they would like to participate, and reiterate that participation was voluntary and their decision regarding participation would remain confidential.
All consultants that wished to take part, and were able to during the data collection period, were interviewed. The estimated total number of whole-time equivalent (WTE) consultants in post at the time was 33, the average number of WTE consultants per site being 7 (minimum 3 and maximum 9). A total of 18 of these 33 consultants in post were interviewed. Informed consent was obtained from all 18 participants. Individual interviews were conducted in a private room at the consultants' ED. All interviews were conducted by the first author. All interviews were recorded with a Dictaphone and the interviewer made brief notes throughout.
Qualitative semistructured interviews
Consistent with IPA methodology, the interview schedule was flexible and non-directive to facilitate the participants in telling their story. The interview schedule (see online supplementary appendix 1) comprised a small number of open-ended questions informed by previous research asking participants about their experiences of (1) stressors and/or challenges at work; (2) how these relate to their psychological health; (3) their experiences of coping in these circumstances and (4) the implications of these experiences on their working career.
supplementary appendix
Research procedures were in accordance with the ethical standards of the University of Exeter (reference number 2013/347). For each ED site, approval was obtained from the corresponding NHS Department of Research and Development, allowing research to take place on site. Identifiable information was anonymised and stored to maintain confidentiality. Standard procedures for the management of distress during or after research interviews were followed.
Analysis
The first author read each interview a number of times, paying particular attention to semantic content and language use, key words, phrases and explanations. Recurrent themes represented shared understandings among the participants and these were explored in detail until data saturation was met. Extracts containing all instances of each recurrent theme were marked and similar recurrent themes were grouped into superordinate themes.
The most articulate or powerful examples within each superordinate theme were selected to illustrate the theme further, with emphasis on similarity and consistency between participants. Instances of marked contradiction and polarity were also highlighted. As a result, each theme provides a distinct representation of thoughts and feelings about an issue.
For purposes of validation, a research supervisor read a sample of transcripts and checked that themes were grounded in the data, representative and constructed in a way that made intuitive sense. Two postgraduate psychologists provided further validation by analysing a sample transcript and generating themes, checking for consistency. Two participants from different ED sites commented on a draft of the analysis, checking the themes for their representativeness.
Results
Eighteen interviews were completed between May and October, 2013. The mean interview duration was 33 min (maximum 48 min, minimum 24 min). Demographic information for all participants is displayed in table 1.
Demographic information of participants (n=18)
The themes displayed in figure 1 emerged from analysis of the EM consultant interviews and aimed to describe consultants' experience of work and well-being in EM. Participants reported working under complex and intense systemic pressures, experiencing mental and physical strain and striving to cope despite these challenges. A number of subthemes describe in more detail the lived experience of being a consultant in EM (see figure 1).
Superordinate themes and their respective emerging themes.
Anonymised participant quotes have been selected to further describe these themes and participants' experiences.
Theme 1: systemic pressures
Participants described the challenges of their role in terms of the pressures placed on them from external sources. These pressures had notable impacts on their clinical work and professional relationships.
Uncontrollable patient flow
…we are all things to all men, we are the place that everyone goes to for advice and therefore we can have long periods where we do nothing but answer questions one after each other, with…junior doctors and middle grade doctors, nurse practitioners queuing up to ask for our advice and input…what makes it especially stressful is that if we have very sick patients…so I will be clinically managing maybe one or two or maybe more patients but still having to be this repository device. (P2)
Compromised clinical risk management and decision making
…what you can do is become safer, you become more risk averse, because you haven't got the time to take the full risk decision… (P8)
Changing sociopolitical demands and expectations
…so the daily thing of coming into work and thinking, so…how many targets are we going to be shouted at and beaten with but are not within our control because it's not about emergency department functioning, it's about onward patient flow, capacity within the wider system. (P6)
Imbalances between demands and resources
… [There are] reduced levels of people wanting to get into the [EM] specialty…which increases the demands on the seniors who are left… (P5)
Theme 2: mental and physical strain
Participants described the impact of these stressors in terms of their physical and mental well-being.
Threat to professional identity
…We’re the default bottom line, if nobody else wants to take it [clinical responsibility]-it comes to us and we have to sort it, we don't have the opportunity to say no.…you feel a bit dumped on at times… (P6)
…From time to time we feel very unappreciated and disrespected…these things undermine feelings of self-worth and without self-worth it is hard to come in and do what you like doing …[it's] pretty undermining….. (P2)
Trapped in a cycle of physical and mental exhaustion
…I can't just walk away from it…even if I feel irritable. You just keep going, you just keep working, you keep organising the shift, you keep answering the questions, you keep seeing the patients. (P7)
…there is doing the best for the patients or the staff and [doing] what's best for me, and they are not the same. (P2)
…if I'm over stimulated I kind of see it like my brain is being trapped on, so I can't sleep and I mull each clinical case over in my mind repeatedly often for several days. (P10)
Uncertainty around individual sustainability
…I can’t conceive doing this job till the age of 65…the current level of stress and constant bombardment and harassment, I couldn't do it. (P6)
…there are a couple of my colleagues who have had time off sick with stress or mental health issues, and you think…how am I going to stop that being me?…there's the potential there for all of us…I don't feel personally I am the sort of person that might get to it, but you never know. (P9)
…a lot of my self esteem and self-worth is tied up in being a doctor so it’d be quite a big step to stop doing it…(P3)
The pain of professional and personal vulnerability
…There are a few episodes in my career that are very vivid, they are all bad without a doubt, because people died or suffered because I was put under… intolerable, stressful positions. (P2)
…it does impact you, you feel a bit funny for the next few days…there are only about 3 or 4 cases that I will never forget…one of them…I wasn't even involved [clinically]…I was looking after [a family member] and she was the most heartbroken person…I can still remember what she was saying, I can still remember where we were sitting, it was just so harrowing…to watch someone fall apart in front of you and physically and emotionally fall apart is very difficult, and I'll never forget that. (P11)
Theme 3: managing the challenges
Participants described adapting to the systemic challenges and physical and mental strain in a number of ways.
Taking satisfaction from one's professional skills
…the day-to-day work on the shop floor is the fun bit, that's why we do the job. It's not stressful, as such. It's stressful in as much as the flow through the hospitals are difficult. But actually seeing an individual patient is never the stressful bit. That's the easy bit. (P17)
Proving one's worth
…the important thing is to be able to continue to introspect, to continue to try to improve, to get feedback and see where the deficiencies are and try to remedy that. (P4)
…I think we get a lot of support and recognition within our department, both from…consultant colleagues, but also all the staff value us…I feel valued. (P8)
Evolving with the pressurised context: developing status, influence and purpose
…you look to do something else, either for your own satisfaction or because you realise that you can't keep plugging away on the shop-floor until you're 65. Because people will, and do, burnout because of that (P14)
…getting the best from your team is massively pleasurable, gives me an enormous amount of support and a great feeling of satisfaction…our job as consultants is to be the umbrella and just keep the [pressure] off of the staff, be it coming from above from the [local health authority], be it coming from the patients….I get a lot of pleasure from running the team; I think most of us do. (P2)
…we meet every week and discuss things that are happening day-to-day but also…our long-term strategic goals… that weekly interaction with your colleagues…if you weren't involved at a strategic level…that would be then very frustrating… (P9)
The EM consultant culture can be reluctant to recognise one's own needs; however, some participants reported recognising these and acting on them.…it would be very easy to come [home] and drink a bottle of wine…you're feeling a bit too tired to…go to the gym…I really do have to be very conscious …to do something healthy, because otherwise the next day you feel worse and the spiral continues. (P5)
…It is difficult to find the time for you to look after yourself…often work-life balance is [about] your family and work, but for you personally, as an individual balance?…people don’t often think about it or give it the time it probably needs (P11)
A sustaining environment: knowing that you're not alone
…you can feel down, you can feel overwhelmed and then knowing that they [consultant colleagues] are basically saying to you, it's not you it’s the system…they are saying ‘we are all the same’. (P12)
…quite often the reaction [to a clinical error] is that the [EM doctor] thinks they should be punished…in my experience they find a lot of comfort in ‘this normal…it happens. (P2)
…colleagues are massive to us, both at a consultant level and as part of the team. One of the reasons I think we tolerate what we do is the team, it's that slight soldier mentality where we are in this together, we can do this… it's what we do. (P2)
An understanding evolved of how participants experience physical and emotional strain, resulting from a dynamic interplay between external pressures and their management. Participants described striving to restore effective functioning to the ED and EM specialty at all costs, prioritising the well-being of others and proving their value (or worth) as a consultant and colleague. The effect of this increased strain leaves consultants exhausted and uncertain about the sustainability of performing with such intensity. The overwhelming pressure leads to the feelings of powerlessness, resulting in consultants exiting early from the role; leaving due to ill mental/physical health; withdrawing from clinical responsibilities and enduring in the role with the aim of improving the systemic problems. These strategies can further contribute to additional pressures and strain (see figure 2).
Summary of results and relationship between themes.
Being unified as a consultant body helps consultants to feel valued and respected, and more able to elicit change. Consultants' increased efforts at an organisational, managerial and clinical level are recognised by fellow ED staff, thus increasing satisfaction by achieving meaningful change for the ED team. This external recognition by others has a positive impact on consultants' sense of self-worth and value. The support, purpose and validation one receives from the ED environment increases consultants' confidence in sustainability. Efforts to support the ED through the systemic pressures are prioritised and a sense of satisfaction and self-worth is perpetuated (see figure 2).
Discussion
In this study, consultants described a sense of satisfaction from clinical aspects of EM work; however, when concurrently experiencing uncontrollable external pressures, mental and physical strain, this sense of satisfaction diminishes under these unsustainable circumstances. Our findings are consistent with the literature review by Arora and colleagues who reported that physicians working in EM had burnout levels in excess of 60% (compared with 38% of physicians in general), yet a high proportion also reported feeling satisfied in their work.14
Relationships between systemic pressures and individual well-being
Workplace psychological theory suggests that the following processes can increase the risk of experiencing poor psychological well-being, including diminished self-worth:
an imbalance between demands and resources (transactional model of stress)15
a lack of satisfaction derived from clinical activities16
being unable to attain additional roles at work (which promote self-definition)17
a lack of opportunity to generate new working relationships within one's role17
The experiences of EM consultants in this study reflect the processes above. As a result of changing demands and limited resources, consultants can feel restricted in working effectively and efficiently. This can limit the amount of satisfaction one usually derives from their clinical work. The presence of these factors makes an individual vulnerable to poor psychological well-being. Experiencing repeated failures in meeting self-worth contingencies can result in negative aspects of the self, and an overall negative bias, to become more salient. This process contributes to the expression of depressive symptoms.18 This self-worth contingency model postulates that self-worth plays a fundamental role in the onset, maintenance and remission of depressive symptoms.17
Role stress and individual stress
Consultants witness their colleagues exit the profession early, leave due to poor mental health, disengage from their work or endure in order to promote meaningful change. This creates uncertainty about consultants' own psychological well-being and functioning. The presence of external stressors diminishes consultants' self-worth and a sense of achievement as a consultant, causing them to strive to retain one's status and achieve meaningful change for patients and colleagues. The increased work intensity creates a cycle of exhaustion, compromised efforts and unacknowledged strain resulting in vulnerability to depressive symptoms and burnout. These processes may help explain the heightened psychological distress that ED physicians and consultants have reported elsewhere.8–9
Participants unanimously identified with the term ‘sustainability’ when describing their emotional and physical status. This suggests that EM consultants identify with a bespoke and less stigmatising understanding of symptoms associated with depression, anxiety and burnout. Consultants did not label themselves as ‘stressed’, preferring to describe their experience as significantly stressful, both physically and mentally, which is perceived to be unrecognised by the public, national health authorities and hospital colleagues. This stress, compounded by a lack of recognition, is perceived as physically and emotionally unsustainable. When participants are striving to improve and support ED colleagues, they simultaneously feel the benefits of their efforts and their specialist skills, thus feeling validated. This validation supports their self-worth, possibly protecting them from the psychological impact of systemic pressures. This striving may protect consultants from burning out temporarily, but is an unsustainable coping strategy in long term.
This research suggests that the lack of external validation and recognition is significant to consultants' lived experience; where self-worth fails to be validated by the system, it is sometimes validated through patient feedback and ED colleagues who participants identify with. An ED identity, and unified ED consultant identity, may protect consultants from stress by providing them with an identifiable means to receive external validation and social support; an effective source of sustainability.19 ,20 Participants described dynamic sources of satisfaction, relative to their ‘consultant’ role and their working conditions; such as protecting the ED team from external pressures where possible and striving to make organisational change. A sense of self-worth may be supplemented by adapting to the stressful context and adopting additional roles and relationships, providing opportunities to ‘fix’ systemic problems in dynamic ways.
The emergence of self-care and compassionate dialogues
This study's emerging themes were largely consistent across participants, which may be a reflection of their unified identity. Some deviations did present themselves in a minority of cases; particularly participants' willingness to prioritise self-care and personal well-being outside of medicine, and openly discussing the psychological impact of decision-fatigue, normalising this with colleagues. Although diverging from the dominant themes in the data, these experiences were perceived as beneficial for well-being and enabled recognition and normalising. Having a dominant unified discourse may make it difficult for such alternative discourses to emerge.
The response rate of participants exceeded expectations. This research may have represented an opportunity for participants to have their experiences acknowledged and validated. It may also reflect aspects of consultants' professional identity; being active in promoting change and supporting colleagues involved in research recruitment. It was vital for the researcher to acknowledge the expectations that participants had for this research. Bias from the first author to pathologise participants' experience and collude with blame was acknowledged during analyses, as consistent with IPA methodology.
The present findings highlight particular risk factors for the development of significant psychological strain and exhaustion: excessive demands, poor self-recognition of one's emotional and physical needs and self-care, poor recognition from others of one's efforts and lack of sustainability of the role. Protective factors are experienced as adopting an introspective approach, social support from colleagues and personal relationships, and maintaining and developing clinical skills. Identifying with one another provides a sense of purpose; where one can exert the skills of an EM consultant and witness the benefits, receive recognition and feel satisfied. Future studies would benefit from exploring these constructs further to establish the generalisability of these findings (eg, self-worth, role development and satisfaction).
Limitations
The prospect of a selection bias in this study is acknowledged. All participants were working full time, and therefore ‘functioning’. Consultants who were experiencing distress that significantly impeded their ability to maintain the consultant role were not included. Although participants worked across different EDs, these were located within the same geographical region of the UK. This participant group may not be representative of consultants working in regions with different patient populations, resources and systemic pressures.
Solutions
ED consultants may benefit from enhanced social support within the ED team; developing a dialogue that facilitates giving and receiving recognition and permission for self-care. It may be beneficial to recognise and normalise the impact of stressors, such as decision fatigue, or investigate alternative sources of external contingencies for self-worth. Promoting role development may protect EM consultants from experiencing role loss when systemic pressures limit opportunities to perform and receive feedback. Multiple-role opportunities may reduce uncertainty and increase sustainability. These measures would support a stigma-reducing means of promoting psychological health in these professions (box 1).
Supporting well-being and sustainability
Promoting social support with the ED team: for example, activities that promote team cohesion, openness, asking questions, providing answers
Generating a dialogue that facilitates giving and receiving recognition: for example, within consultation groups, team meetings/discussions, psychosocial and stress management training
Granting permission for self-care: for example, giving others permission, giving yourself permission; ‘nudging’ the system into more compassionate ways of working together
Recognising and normalising the impact of stressors: for example, decision fatigue, relating to a patient in traumatic circumstances, out-of-control shop-floor; knowing you're not alone in experiencing these
Offering role development/choice to support role loss when systemic pressures limit one's satisfaction and self-worth: for example, offering choice and new skills
Conclusions
This study found that EM consultants experience considerable physical and mental strain, which is dynamically related to highly demanding, uncontrollable working conditions. This strain influences consultants' experiences of diminishing self-worth and satisfaction, alongside current sociopolitical demands on EM services. Recognising the psychological experiences and needs of EM consultants by promoting a sustainable EM consultant role could have wide-reaching benefits for the delivery of emergency care and address the needs of doctors at the risk of experiencing clinically significant levels of stress and strain.
supplementary appendix
Acknowledgments
The authors would like to thank the lead emergency medicine consultants of each department involved in this study, for their support in the recruitment process, and also to all the consultants who acted as participants in this study, volunteering their much-valued time and insights. The details of supportive services for any medical practitioner who may be experiencing significant distress are also included (see online supplementary appendix 2).
References
Footnotes
Contributors As lead author, KF led the planning, conduct, and reporting of the work described in the article. PY, JB and AH supported the planning and recruitment process from an academic and clinical perspective. PY supported KF in reviewing the analysis conducted by KF. PY, JB and AH reviewed and edited the manuscript. These were the only people involved in the study and article.
Competing interests None declared.
Ethics approval University of Exeter.
Provenance and peer review Not commissioned; externally peer reviewed.