Apathetic & Emotionless. Is this really what our A&E staff have become?
If there’s a story about A&E in the news, it’s usually something about horrendous waiting times, or the latest grim failure in performance targets. Worryingly, I’ve recently noted the emergence of stories highlighting instances of poor attitude and behaviour from A&E staff. Channel 4’s recent Dispatches program, “Undercover A&E”, talked about “disgusting care” from “compassionless staff”. Some newspaper journalists have shared their own A&E experiences, describing “dead eyed staff” with “a frosty demeanour”.
As an
A&E doctor myself with 16 years’ experience as an NHS consultant I find
this deeply troubling. Undoubtedly the most disquieting point in the
media is the implication that the A&E staff simply don't care about the
suffering of their patients. Pain and distress are overlooked. Indignity goes
unnoticed.
So, what is
going on? How can those in whom we put our trust to help at a time of crisis
and pain be so indifferent to our need?
It wasn’t
always this way. As a junior doctor in the late 1990s, I was attracted to
working in A&E by a sense of action and challenge but also by the team
ethos in every A&E department. Nurses and doctors pulling together, dealing
with whatever came through the door and delivering fantastic care which blended
modern medical technology with a warm human touch. Media attention tended to
lavish praise and admiration for our work. A quarter of a century later however
it’s difficult to find a description of A&E that isn’t troubling in some way.
The crisis
in A&E, if we’re going to call it that, is not a recent phenomenon. For
many years we had a “winter crisis” across the country with A&E departments
overwhelmed by mainly older patients with respiratory conditions. The crisis is
now multi-factorial and no longer just seasonal. In A&E we’re living in a
Narnia like eternal winter. Departments are ceaselessly overcrowded, with
patients squeezed into every conceivable space, almost as if there were elastic
walls. The human cost in lives of this overcrowding has been well documented by
the Royal College of Emergency Medicine, with a 2023 estimate pointing to 250 excess
patient deaths per week.
Now let’s
consider the impact on the A&E staff for a moment, the doctors and nurses
who are working in this state of “permacrisis”. All of us went into A&E to
do a good job. We are generally sincere and caring people who chose a career in
A&E as we had a strong desire to help the sickest patients. It hurts us to witness
suffering daily. It hurts us not be able to move patients from an uncomfortable
trolley in a corridor to an actual bed. It hurts us when we hear the shout of
abuse from a disgruntled relative. It hurts when we ask for help and are told
‘No’. These hurts and many more besides are a daily occurrence. Each is a small
cut, or trauma perhaps. These small traumas add up over time and the end result
is Moral Injury.
Moral Injury is the consequence of repeated negative experiences where something clashes with one’s sense of morality or what is right. While more readily appreciated in soldiers returning from combat in past wars, it is unquestionably being seen in the A&E staff of today. I believe this Moral Injury is a key factor in why so many A&E staff are experiencing burnout and displaying some of the behaviours witnessed in the media today.
Burnout has
3 principal components: exhaustion (both physical and mental), poor performance
and lack of empathy. It is the latter of these which explains the “compassionless”
or “dead-eyed” nurses and doctors. Staff who are experiencing burnout are on a worrying
downward trajectory towards either ill health themselves, or the exit door from
A&E altogether.
Crucially,
the blame for burnout and the behaviours that go with it, lies with the system in
which the individual is working and not the individual themselves. I’m
certainly not dismissing indifference or excusing apathy; I just want to
highlight why we are seeing it. Yes, we need to be better. Yes, trust
has been eroded. A&E staff know this, but so many are paddling hard right
now just to stay afloat. They are not angels. They are certainly not
superheroes. They are just ordinary, decent folk.
I work with
fantastic people in my own department, some of the best around. I know many A&E
colleagues around the country who would say the same. If we want our A&E
staff to be energised and warm-hearted once again, then we urgently need to
change the system they work in. Hopefully, the recognition by our new government
that the NHS is “broken but not beaten” will lead to the change we need.
As a journalist who writes on health I believe that we have a duty to be impartial and consider the views of everyone involved in a story. We all have as members of the public, a duty of care to our health care professionals, especially those working in the NHS. I use the description “our” because it is our NHS and not the Scottish or UK governments’ NHS. Any poor treatment of NHS workers and indeed patients because of staff shortages and poor funding is happening on our watch.
ReplyDeleteThank you - very well said. We will see if Lord Darzi's report translates into meaningful action.
DeleteI can see it from both sides having been a nurse in A&E and on the road in an Ambulance. Total of 48 years service in various roles. I can recognise that some staff dealing with what they have to deal with lose a certain amount of compassion and empathy partly as a protective mechanism. You also have staff who always were adrenaline junkies which is what attracted them to A&E work in the first place but causes them to lose sight of the patient at the end of the situation.
ReplyDeleteThe problem from my perspective is that successive levels of senior management seem to be immune to the fact that decisions they make are what create the conditions that impact staff and cause them, in a minority to behave the way the headlines suggest.
I can exactly date this to the ideology that took hold amongst decision makers 15 years ago, that saw the way ahead was to cut acute beds and pretend there's the support in the community to cope with trying to maintain sick people at home. The net result has been intense pressure on A&E departments and ambulances sat outside departments for hours on end.
From my personal experience it's completely soul destroying to have to sit with an unwell person in the back of an ambulance for hours on end making up every excuse under the sun for the awful treatment they are having to endure. The worst wait I've experienced with a patient was 9 hours.
No matter how much you try to maintain your humanity it's difficult when you cannot sort the problem out and it's not what you came into clinical care to do.
For me those times are mostly past but I do have a real fear of ever having to be a patient!
I've spoken with paramedics who have had the same soul destroying experience of sitting outside A&E for hours with a sick, often frail patient and what they describe clearly amounts to moral injury too. Wanting to deliver good care to the vulnerable, but being unable to do so, is psychologically draining.
DeleteNothing spells out just how broken the system is for me than a queue of ambulances outside A&E, unable to offload their patients.
Calvin, Once again you have crafted a very thought provoking, to the point, proportionate and pragmatic article. The challenges faced by the health service will most definitely not be resolved anytime soon. Considering how we can more affectively redirect inappropriate presentations allowing you and your team to continue to provide care to those most in need, with adequate resources in less challenging conditions. Only then will we be more able to ensure the best possible outcomes for the health and wellbeing of both patients and staff.
ReplyDeleteThank you for the lovely feedback, much appreciated.
DeleteInappropriate presentations are a consequence of failings elsewhere in the healthcare system - and the solutions lie out with the A&E department. I think we need to be mindful of not blaming patients for NHS failings.
100% to all above Lack of foresight by management and politicians , not enough Staff recruitment , to many bed cuts ( to able patients to move to a ward , therefore blocking A&E ) closing Community hospitals for patients to recover fully in. Are the main problems . Come sense to me as a retired ambulance service member . How many times can you cut a piece of string before you can’t tie a knot in it !!!! A&E was never supposed to be a holding centre really come on let’s get it sorted this time . To many valuable staff are getting beaten into the ground and leaving as a result ( mostly unwell/ burnt out/ fed up because nothing is being done to sort this problem 👍💔
ReplyDeleteThank you, so true. What you describe has been many years in the making and the current trajectory is deeply concerning...
DeleteThis is such a great article Calvin. I worked in ED for 15 years and it was my absolute passion, I loved it. Thrived and excelled at work. Then post COVID the daily moral injuries became too much, the burn out was too damaging, I could no longer look after people the way I used too, patients were not receiving the care they deserved, the dread of going to work everyday knowing it's going to be as bad as the shift before was like groundhog day. I couldn't do it anymore. I had to leave for my own sanity, a decision that really broke my heart, but I had to go. Friends who still work there tell me it's even worse than it was 2 years ago when I left, it's so sad and heartbreaking for everyone. ED was such a special place, the best teamwork. I fear the day myself or my family are ill and have to attend.
ReplyDeleteKeep up the good work Calvin, you are one of the very best consultants around.
I left the NHS in 2015 and moved to Australia, like many others. So much more resources but still have issues with demand outweighing capacity. Our ED sees 300-350 pts per day and we often have pts in our Dept for 2 days, it’s insane. As much as we try to promote wellness, burnout exists in every ED regardless of which side of the world you work in. Some days are exhausting but most are rewarding. Having 48 nurses on a shift is very different to the 9 nurses I had in my old department back home. I worked in the same trust as you but in another ED. I’m still very passionate about being an ED nurse, but it’s very different to what it was like when I started in ED 20yrs ago. As a senior nurse, I have seen many good nurses burnout and leave. They recognised how their practice was impacting their ability to be empathetic and some have left the profession altogether. One thing that remains is how we are directly protective of our colleagues and will rally round to look after them when burnout strikes.
ReplyDeleteSo very true. The issue with burnout of ED staff seems to affect all Western countries. As one former colleague put it - "we are the collateral damage".
DeleteBest wishes for the future with the Australian ED family.
Amazing article Calvin. As always a balanced approach. As others and yourself have said this did not happen overnight. As an ED nurse for the last 20yrs (including a small period of time with yourself) ED is not what it was all those years ago. Patients are more complex - the amazing power of modern medicine and new treatments- but that often leads to longer stays in hospital.
ReplyDeleteThat in turn means we don’t have the turnover in beds for us to admit to from ED. Which means patients stay longer in the ED dept- often at unsafe levels.
We’re also seeing staffing budgets frozen or cut which means despite the growing number of very sick patients in ED we’re trying to look after them with less staff. We can’t provide the care we desperately want to.
Hopefully we see some change soon. Hope you and the team are well! Make sure you’re all looking after each other and yourselves!
Absolutely - the trend you describe simply can't continue. Words and empty promises just aren't going to cut it.
DeleteBut how do we get it to change?
DeleteDecisions higher up, particularly where I am now, are made based on money and more often than not by people with no actual nursing/medical background.
Our patients are being failed and it’s not the fault of the frontline staff. More often than not these staff are working through breaks and pushing themselves too far trying to do the job of two or more staff.
I left nightshift this morning with more than 30 patients waiting more than 4hrs for beds (most of them waiting greater than 10, some nearing the 24hr mark). That’s not an ED problem - but it’s ED and Assessment Units that bear the pressure, from management and patients/relatives.
I’m completely lost at how we get those making the decisions to see that we’ve gone down the wrong road and we need to turn off it asap!
As a paramedic who often attends your hospital i can firmly confirm that I am one of those "dead eyed" health care workers. I have seen the system worsening over the last 20 years but in the last 5 I would say it has fell off a cliff. Chronic under funding of services along with erosion of community based care has caused a massive problem. Ambulance Service and A&E are now the primary route most people seek out when ill. I am on the look out daily for another job away from health as my own physical and mental health have taken a massive beating lately.
ReplyDeleteSo sorry to hear that, but entirely understandable. You are certainly not alone. Making your own wellbeing a priority has never been so important. We are all expendable at the end of the day...
DeleteI don’t think management understand the how draining it is on Ambulance crews to be stacking at hospitals. Not only are we not trained or equipped for long term care, we are also fully aware that whilst we are stuck at A&E, there are patients in the community who need our help. Recently there was a fatal multi vehicle RTC five minutes from our Divisional HQ and ACC couldn’t despatch a single local crew… I was in a stack of 5 vehicles awaiting ward admission whilst this was going on…
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