'It's Like Being In A Warzone' A&E Nurses Open Up About The Emotional Cost Of Working On The NHS Frontline

As nurses prepare to strike for the first time, an A&E nurse and lecturer in Organisational Behaviour in Healthcare writes about the stress, fear, grief and guilt they feel every day working on the frontline of an NHS in crises.

This was how one nurse in her 40s described an Accident and Emergency (A&E) department to me, and it sounded all too familiar.

The resuscitation area in the emergency department is a hive of time-critical activity as staff weave around one another at pace. The sheer din is intense: a symphony of alarms, voices and crying out – all varying in pitch and volume, competing with one another. The bays are awash with wires, pipes, medical equipment and pumps to give various medication.

This is the norm. But some nights will always stand out above the others. Once, while I was on shift, a three-year-old girl in a nearby resuscitation bay was receiving treatment for meningitis. Following a substantial and sustained attempt at resuscitation by the paediatric team, she died.

I wasn't caring for her directly, but it was apparent from the noise how the treatment was progressing and when, ultimately, it was unsuccessful. The screams and cries of grief from the girl's parents were heard above all other noise when staff broke the news to them that their child was dead. It was unforgettable.

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Many of the adult patients were too unwell to know what was going on. So, despite the communal awareness among staff of the enormous distress close by, we carried on caring for our other patients, offering them the“reassuring face” and warmth they expected. I stood behind one of the curtains for a few moments and swallowed hard at the sounds of the suffering. And that was it. Sadness and distress at the death of a child had to be suppressed for the sake of the other patients.

On the drive home I reflected on the emotional complexity it requires to be a nurse. The need to hide sorrow while juggling great workloads, the pressure of organisational targets and other patients' seemingly less critical needs requires intense effort and emotional control. That effort is exhausting and draining.

This tragic incident was just one of many similar experiences I have encountered over my 11-year career as an A&E nurse. Heartbreaking and emotionally complex stories like this happen every day in A&Es up and down the country. Nurses have to conceal myriad feelings as standard just to get through their shifts. This includes harrowing, disturbing and traumatic emotion as described in the story above, but also fear and anxiety when they feel overwhelmed and have to deal with aggressive situations. Nurses experience joy and relief when a patient recovers against the odds but frequent guilt and shame at being unable to deliver the standard of care they desire.

The exploration of emotional labour in emergency care has underpinned my subsequent research career . It has motivated me to explore and support this under-recognised area of nursing practice.

“emotional labour” is a theory coined by sociologist Arlie Hochschild who defines it as“the management of feeling to create a publicly observable facial and bodily display”. When that toddler died of meningitis, myself and the other nurses did our own emotional labour by suppressing our true emotions to ensure the other patients in our care felt reassured. In other words, we remained“professional”.

But the nurses I spoke to are not only dealing with emotions related to grief and bereavement. Because of the crisis facing the NHS, many feel they can't do their job properly and so have overwhelming feelings of guilt too. A male nurse in his 30s told me:

A recent analysis by The Kings Fund showed the extreme pressure the NHS is under. More patients than ever are experiencing delays in cancer diagnosis and treatment and longer waiting times in“non-urgent care”.

These pressures have an impact on patients, but also affect those tasked with delivering care. Nurses are quitting in record numbers . By 2030-31 half a million extra healthcare staff will be needed to meet the pressures of demand – a 40% increase in existing workforce. Health and social care staff are exhausted and the workforce is depleted . The negative impact of this crisis cannot be underestimated for both staff and patients.

When nurse staffing is short or lacking in the required skills due to issues like high staff turnover and sickness, research shows that patient mortality is higher and patient experience is poor .

Nurses working in short-staffed areas are twice as likely to be dissatisfied with their jobs, to show high burnout levels, and to report low or deteriorating quality of care in their hospitals. This becomes a vicious cycle as these experiences fuel more staff to leave.

sickness absence rates in the NHS are higher than in the rest of the economy and 47% of staff felt unwell in the last 12 months as a direct result of workplace stress. One study has shown levels of Post Traumatic Stress Disorder similar to those experienced by soldiers in Afghanistan.

A recent evaluation found that poor mental health and wellbeing among medical staff is costing the NHS about £12.1 billion per year.

In England, NHS patient attendance to A&E has followed an upward trajectory over the last 70 years. In 2019-20 there were 25 million attendances, compared to 21.5 million attendances in 2011-12.

Patient attendance has been growing exponentially in the last ten years. This, together with rises in patients who need admitting to hospital for routine care, fewer hospital beds and staffing pressures has resulted in unsafe patient overcrowding in A&Es. research has shown how overcrowding increases adverse clinical outcomes including death, medical error and decreased patient satisfaction.

The most recent figures for 2022-23 show the worst A&E performance (waiting longer than four hours) on record.

Perhaps unsurprisingly then, those working in emergency care are more likely than other healthcare workers to experience poor wellbeing , suffer psychological illness and to quit their jobs.

According to the Royal College of Physicians, NHS staff are the greatest asset of the NHS and are fundamental to delivering high-quality care. Staff go“the extra mile” as standard: they work without breaks, come in on their days off and often stay unpaid, long after shifts have finished.

My phd aimed to understand the experiences of nursing staff in A&Es and how they managed their emotions to cope with these challenges and still meet patient expectations. This is critical because emotional labour, in particular, is linked to wellbeing and burnout.

I worked with a team of academics to undertake an ethnographic observation study across two large NHS trusts in the UK. This involved 200 hours of observation and 36 in-depth interviews. We spoke to A&E nurses of all seniority and support staff in both organisations. We found that the nursing staff“did” intense emotional labour routinely in their work. As one male nurse in his 30s explained:

The nurses adapted their emotional response to support a vast spectrum of patient need. Among these complex and intense emotions, we heard examples of nurses who felt scared, guilty and endless examples of nurses being short on time and resource, feeling stressed, and grieving over patients who died. They hid their true feelings to make sure their patients felt safe and to build trust – whatever the circumstances. They moved at pace between groups of patients and adapted their appropriate“professional” response.

We collected data over a six-month period and found that the nurses used various metaphors to describe experiences of managing their emotion in A&E. We found some key themes.

Nurses described to us how sometimes the environment can feel overwhelming, using that“warzone” phrase to explain their experiences. This sense of relentlessness and“combat” has implications for the nurses emotional labour too. Their nursing values (related to providing care and compassion) are conflicted with the realities of contemporary practice. The standards of care possible amid the operational pressures don't reflect these nursing values (built on warm and reassurance).

The nurses I spoke to weren't able to deliver the quality of care they wanted to. This means they needed to suppress the associated frustration and guilt. There was a sense of genuine sadness and even shame that they couldn't give their patients the time or connection they longed to.

This former nurse said one incident in particular“changed her outlook on A&E” and led to her thinking,“I can't work here anymore”.

Instead of meaningful patient and nurse relationships, the care delivered in A&E often feels transactional and lacking emotional connection. Interactions were quick and task based. Again this results in the nurses feeling dissatisfied and often guilty. jill maben , a professor of health services and nursing, found that when nurses are unable to deliver the care they want to, it doesn't line up with their values. This disconnect (between values and reality) can be a reason why nurses leave the profession.

The clinical realities of the nurses work went against their deep moral values and the desire to care. This was reflected by many of the nurses I met, including a female nurse in her 40s, who said:

For some of the A&E nurses interviewed in the study, the inability to deliver the standard of care they wanted to was unmanageable and they left. One told me she quit because A&E was so busy it meant ignoring some people who were waiting long hours. She said:

Sometimes the nurses said they were scared: scared of the overwhelming workload as well as the threats and intimidation they received from patients. One of the nurses, in her early 20s, described how she“put on a front” to her patients. She did this to hide any anxiety around her inability to cope. She was protecting her patients from her true emotion and as a result, making sure they felt safe:

She said it was important not to let patients see that they were“stressed and flustered” because“it gives them reassurance ... to show patients that you're confident and you can get on with it”.

Again the nature of this emotional labour (this time suppressing fear and anxiety) is guided, in part by the need to protect and reassure patients under their care. Another nurse, in his 30s added:

For some, the extraordinary feeling of stress involved is overwhelming but the nurses stay calm and professional outwardly, as described by a female nurse in her 30s:

She added that the same amount of pressure and noise could amount to“torture” for some people.

But sometimes the stress was related to fear and anger when dealing with an aggressive and abusive patient. Again the nurses emotion remained hidden and out of sight of the patient and others in the waiting room. One nurse described an incident on a particularly busy night with man who was getting tired of waiting with a minor injury.

She offered him assistance, as he was struggling to walk. But he shouted at her in front of a full waiting room, including children:“Why don't you just fuck off and die?”

The nurse was shocked. The entire waiting room was staring back at her. She said she couldn't speak and that her“blood was boiling” but she was also frightened. She couldn't engage with him so she walked away, afraid she would shout back or cry if she tried to speak.“Had I been outside of work, I wouldn't let people speak to me like that,” she said.

She added that if those unruly and abusive patients were shown a baby being resuscitated in the next room they might rethink their behaviour and show more respect.

But all feelings must be managed, even sadness and grief – perhaps these emotions above all.

This female nurse said that managing emotions like this meant some nurses might sometimes come across as“hard” and“cold”.

But being able to relate personally to the patient or their family, although helpful for the patient, can take a heavy toll on the nurse. One nurse got upset when telling me about the time she was pregnant with her little boy and was resuscitating a baby.

Operational pressures in A&E and elsewhere in the health service squeeze the time nurses have with their patients. The fact many are unable to deliver the standard of care they long to contributes to nurses leaving the profession as described above.

And those nurses who stay can become so burned out that they can suffer with compassion fatigue : a protective mechanism in which nurses become emotionally“shut down” and as a result, can fail to notice and respond accordingly to trauma and suffering. This shows that the health – particularly the mental health – of nurses and doctors can directly impact patient care.

Read more: 'we will not forget our colleagues who have died': two doctors on the frontline of the second wave

We need to understand the emotional complexity of nursing and other healthcare work. In understanding it, we can value it.

Nurses are not angels , they are human beings, with the accompanying full spectrum of emotions. At their best they can offer life-changing support and compassion. But they need the resources and support. There is only so much stress, fear, grief and trauma a person can cope with before burning out completely.

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