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A new study published in the BMJ Open looked at the need for recovery amongst emergency physicians in the UK and Ireland.

“Our study is about using a tool called the Need for Recovery scale (NFR) to understand the physical and psychological impact of shift work in emergency departments in the UK and Ireland,” study author Laura Cottey told us. “We know that emergency department staff work long, consecutive shifts often with a high proportion of out of hours work coupled with overcrowded and understaffed departments.”

In addition, added Cottey, rates of burnout and impaired staff wellbeing within this healthcare group is known to be high. However, despite an increased interest in this area there is very little evidence to understand how best to make improvements or a tool to measure the impact of any intervention. Assessing burnout is too late and there is a need to find a tool that is quick and easy to identify early impaired staff wellbeing.

Researchers hypothesized that the NFR, an 11-item yes or no survey providing a score of 0-100, 100 being the highest possible score, could be that tool. 

“We were anticipating finding a high need for recovery score within the population surveyed but more importantly we were hoping to be able to identify what factors increased and decreased your score so that we could make evidenced based recommendations to influence policy.” 

Previous ‘need for recovery’ population based scores had a range of 36-44 out of 100. Researchers had previously conducted a feasibility study within one emergency department in the South West of England which had found the median score to be 81.8 so they did hypothesize they would find a high score. 

“This study was conducted prior to the challenges that COVID-19 have placed on our healthcare systems however emergency departments across the world were already experiencing difficulty in recruiting and retaining emergency medicine doctors and other healthcare staff due to the perceptions of increased workload, high proportion of out of hours work and stressful work environments,” study author Tom Roberts told us. “The topic of staff wellbeing and staffing was identified within the top ten key research priorities through a priority setting process but had also been regularly highlighted as a important issue through national surveys conducted by professional bodies.”  

The aim was to determine the median NFR score in emergency physicians across the UK and Ireland and to understand the factors associated with a higher NFR score. 

“To do this, we were fortunate to be the inaugural research project for the national Trainee Emergency Research Network (TERN) a new collaborative network of Emergency Medicine trainees across the UK,” study author Blair Graham told us. “This project allowed emergency medicine physicians who may have not previously engaged in research before to become the lead for their emergency department. This collaborative nature ensured a very high participant response of over 4000 participants.” 

Over 4000 participants responded to the survey, from across 112 emergency departments in the UK and Ireland. Considering how busy the researchers know emergency physicians are, this level of involvement in research represented an incredible achievement. It was made possible, say the study authors, by harnessing a collaborative approach to research, and the goodwill of many enthusiastic colleagues who took on the responsibility of helping coordinate this project, in addition to their everyday workload.

“We tend to think of 70 per cent as an acceptable participant response rate for research surveys because below this level the results might not be truly representative of the population we’re studying,” study author Daniel Horner told us. “We were therefore thrilled to learn that over half of our sites exceeded this benchmark, which was in no small part down to the efforts of these colleagues.”

Perhaps the most important result say the study authors, is the overall need for recovery score amongst the participants. This was 70 out of 100, which is higher than reported elsewhere in the literature and does imply that emergency medicine physicians have a very high need for recovery.

"Other international studies look at NFR in some occupations we might also consider arduous—such as in seafarers who assist the Royal Navy—so it is concerning that emergency physicians scored so highly,” study author Kara Nicola Stevens told us.

Researchers also attempted to determine the relationship between need for recovery and some factors related to participants and their work. To this end, it is particularly valuable that they determined ease of access to study leave and annual leave to be inversely proportional to NFR score. That is, the easier leave was for participants to obtain, the lower- and more favourable- their score.

“These findings are of such significant interest as they represent something that employers and institutions can potentially modify moving forwards,” study author Doyo Enki told us. “Some other interesting associations included a tendency towards lower NFR score amongst males, those with increased experience and clinical seniority, and those who worked in paediatric (child) only centres. Whilst potentially interesting, we need to do further work to explore why these factors might be implicated—whilst it might seem tempting to make assumptions, our current data would not support these.”

Recruitment and retention issues amongst emergency physicians have been an issue in the UK for many years, and although much work is being undertaken by organizations such as the Royal College of Emergency Medicine and Health Education England to positively overcome this, the study authors explained that anecdotally, these problems are likely to be linked at least in part to work intensity.

“And to this end, life in the emergency department certainly isn’t getting any easier—attendances to the ED are increasing year-on-year, many would argue without a proportional increase in human or physical resources to match this rising demand,” study author Mark David Lyttle told us. “So these really are ongoing concerns and it was not a surprise to learn that NFR is high amongst our population, although perhaps we didn’t expect to be such an outlier compared to the other occupations that have been studied.”

The study team thinks these results provide a uniquely robust dataset that confirms the high intensity of working in emergency medicine in the UK and Ireland.

“We have confirmed without much doubt that we do have a significant problem,” study author Jos Latour told us. “We, therefore, hope that this study will not only highlight the need for change but will empower employers, institutions, and the broader health system to make a strong case for positive change, which will improve working lives for our emergency physicians and, in turn, we would hope may also stand to improve safety and clinical outcomes for our patients. Whilst we can’t modify someone’s gender, their age, or even their workplace, there are some factors which appear to improve need for recovery which can be acted upon—and ensuring easy access to leave for vacations and study appears to be key.”