Psychological Support in the ED

Author: Charlotte Davies / Editor: Nikki Abela / Codes: / Published: 25/02/2025

We know that Emergency Department (EDs) across the world are struggling, and the huge amount of pressure that is putting on all of the staff. RCEM is doing their best to raise awareness of the problems, and I for one, am glad to be part of a college that continuously challenges the rulers of this country. But RCEM cant solve the crowding problems, so for the next few weeks (or if were honest, years), were going to have to live with them. But how? We dont have all the answers, but here are some thoughts – but more importantly, an acknowledgement that we are in this all together, and were here for each other. Wed really really appreciate your thoughts, comments and wisdom – together, well get through this.

Weve been writing on, and talking about crowding for a long time – revisit our updated blogs here – and we wont re-visit that, but well just touch on some key wellbeing features.

General Psychological Support

As individuals we need to look after ourselves, and our team, whilst recognising the positive effects of stress! RCEMLearning has lots of wellbeing resources available here and RCEM has an excellent whole page of resources highlighted here as well as many key documents from the sustainable working group.

We know resilience isnt the answer to everything, and that were all fed up with being resilient. Thats true. But we also know there are protective factors to stop us getting burnt out, and whilst this isnt the whole story, we need to do everything we can to keep ourselves safe. Seatbelts wont save you from everything – but we still use them to do everything we can to keep ourselves safe.

What are we mitigating?

Our general suggestions are written with the aim of reducing moral injury, compassion fatigue and burnout – three different but linked conditions. workplace factors do contribute to all three of these- we are just focusing on personal factors. One could say we want to improve wellbeing (which is different to happiness – read here. How we improve wellbeing is difficult to evidence – wellness workshops dont work (The Compassion Fatigue Workbook).

We all like things we can measure. Why not start with an assessment to see where YOU score for compassion fatigue, burnout and moral injury. The survey looks at the last 30 days. How do your colleagues do? Have a look at ProQOL here. As you do it, consider – When we keep ourselves numbed out on adrenaline or overworking or cynicism, we dont have an accurate internal gauge of ourselves and our needs, Trauma Stewardship, Laura van Dernoot Lipsky.

Compassion Fatigue

An occupational hazard affecting some of those who do their work well. (pg. 9 The Compassion Fatigue Workbook, Franoise Mathieu)

This is where repeated (i.e. cumulative) exposure to suffering causes emotional and physical exhaustion.1 It is similar to burnout, and often confused with it. Burnout is defined as chronic exhaustion resulting from the mental and physical demands of daily life, culminating in emotional fatigue, depersonalisation and perceived lack of accomplishment. Some say compassion fatigue is a type of burnout.2

Have a listen on your podcast player to the now archived Jan 2018 podcast from about 1hr 11min where, Caroline is an ED and PHEM consultant in Coventry talks about compassion fatigue.

Compassion fatigue may initially present as an irritability with co-workers and feeling that youre doing all. The work. You may start to avoid meetings and then get fatigued and exhausted at the end of the day. You become bitter at work, with guilt, resentment with eroded compassion. You may have an exaggerated sense of responsibility – I cant leave. How often do we see this in EM? I cant take my break the waiit is soooo long.

Fig.1

An impaired ability to make decisions – our colleagues may not be struggling with their seniority but just suffering from compassion fatigue.

Protective features include having control over work intensity and a variety of roles. Having a higher standard of care may increase the risk – but we wouldnt suggest lowering standards!

When compassion fatigue is present, it is harder to implement these protective features, making continued and worsening compassion fatigue more likely. To reduce likelihood of compassion fatigue we need to ensure coherent and supportive teams, periods of debrief and downtime after traumatic events, awareness of compassion fatigue, and mechanisms for patients to express gratitude.

Burnout

Weve covered burnout in other blogs: Burnout, Burn-ED. The key bit is to get your protective factors present.

Moral Injury

The term moral injury has been used to describe the psychological effects of bearing witness to the aftermath of violence and human carnage or failing to prevent outcomes which transgress deeply-held beliefs. The effects are cumulative and started before covid, although were compounded by covid.3,4

Moral Injury is covered well in this EMJ article by Esther Murray, St Emlyn’s and our October 2018 podcast covers it – available in archive form only.

There is an overlap between moral injury and PTSD, but it is possible to have one without the other and moral injury often doesnt involve a threat to life. There is a moral injury distress scale – it would be interesting to assess this in our current workforce, but I worry it would highlight how much the unacceptable has had to become acceptable.5-7

Prevention is better than cure:

  • Social support
  • Ability to debrief with honest, open conversations8,9

General Strategies

1. You can not (at the moment) change the crowding problem. You can not change what has happened before your shift started. Stop investing any mental energy in trying to change the things you can not change. Please comment below with the things you can not change.

2. Be in top physical form

This counts as putting your own oxygen mask on. Hospitals will be crowded whether you cook yourself a nutritious meal or not. View our previous articles (Wellness Compendium) already and highlight them to your non EM colleagues.

Sleep: Sleep is essential (here and here)
Nutrition: Eat well. Delivery meal boxes are still allowed.

3. Recognise and manage your stress

Read the RCEMLearning Stress Blog. Dont just read it though, talk about stress and how to manage it with all your colleagues both in EM and out of EM. I delivered the simple stress lecture and opened by saying How do you know when Im stressed. At least 5 accurate signs were presented. When I asked how do you help when Im stressed, the room went silent. By talking about it, it really helped normalise the potential of stress. Does crowding cause you stress?

Employ relaxation strategies – mindfulness, hypnosis (e.g. 5min relax and recover, ISH, NHS in mind). A full body scan exercise can be very useful.

4. Be Kind and Recognise and manage everyone elses stress

Consider why people (colleagues, patients, relatives) are anxious just because youre not (although you probably are!), doesnt mean they shouldnt be read this article on recognising anxieties. Maybe they dont know from a patient perspective how ventilation works? This is discussed by St Emlyn’s here. Children might have different anxieties discussed here. People might just be in a different spot to you .Theres a useful leaflet from Mind about reducing general anxiety, and an excellent article on managing your own mental health from BBC coronavirus.

Be kind – it may seem obvious to you that a patient can temporarily move to the plaster room from the corridor for a PR – but not to the surgeons. Everyone is likely to be making decisions at maximum bandwidth (our blog about situational awareness). Be polite about other specialties (including GP) even if you think theyve done something daft.

5. Debrief

Were great at debriefing after a significant event, but should we be debriefing after crowded shifts? We have some debrief thoughts in our April 2020 podcast. Not all debriefing needs to be formal I love the idea of a wobble room, and even just asking how are you, and not all debriefing needs to be after the event consider a time out. The cold debrief structure is often similar to the simulation style debrief.

The informal debrief in the coffee room is great – if both sides of the process have choice in the process. Limited disclosure may help – start with the least traumatic information.

6. Arrange Practical and Wellbeing Support

Period boxes, fare box, too tired to travel home box, peer support for all things, including grocery supply, are useful.

7. Identify what gives you positive energy

If you get joy from cooking – cook! If you get joy from seeing bizarre symptoms or drunk patients – see them, and gain that protective positive energy.

Hopefully, this has been a useful overview – please put your comments and suggestions and resources in the comments.

References

  1. Crowe L. Identifying the risk of compassion fatigue, improving compassion satisfaction and building resilience in emergency medicine. Emergency Medicine Australasia, 2016, 28: 106108.
  2. Hunsaker S, Chen HC, et al. Factors That Influence the Development of Compassion Fatigue, Burnout, and Compassion Satisfaction in Emergency Department Nurses. Journal of Nursing Scholarship, 2015, 47: 186-194.
  3. Murray E. Moral injury and paramedic practice. Journal of Paramedic Practice 2019 11:10, 424-425.
  4. Moral distress and moral injury. Recognising and tackling it for UK doctors. British Medical Association (BMA), 2021.
  5. Norman SB, Maguen S. Moral Injury. PTSD: National Center for PTSD, 2024.
  6. Moral Injury and Distress Scale (MIDS). PTSD: National Center for PTSD, 2024.
  7. Williamson V, et al. Moral injury: the effect on mental health and implications for treatment. The Lancet Psychiatry, Volume 8, Issue 6, 453 – 455.
  8. Murray E. Moral Injury during COVID-19. St Emlyns, 2021.
  9. Carley S. Podcast Moral Injury in Emergency and Pre-hospital care with Esther Murray. St Emlyn’s, 2018.