SLO 7 – Deal with complex or challenging situations in the workplace

The Emergency Physician frequently needs to manage specific shop-floor situations or circumstances that have the potential to significantly impact upon patient care or the functioning of the Emergency Department. These may relate directly to interactions with patients attending the ED, other agencies attending the ED, challenging professional interactions or events that impact on the delivery of EM care. These can not necessarily be predicted, other than they will happen at some point and this learning outcome is concerned with readying the EM physician to deal with them effectively

These situations may involve issues pertaining to consent, capacity and confidentiality with the subsequent need to communicate decisions clearly and to effectively  resolve areas of disagreement or conflict. In managing these situations, the Emergency Physician needs to operate within a specific legal and ethical framework as defined by legislation and guidance from the General Medical Council, the Royal College of Emergency Medicine and other significant professional bodies.

The Emergency Physician needs at all times to behave in a professional manner with patient safety as a priority, whilst working in a multi-disciplinary team that interacts with personnel within and external to the Emergency Department.

Domain 1: Professional values and behaviours
Domain 2: Professional skills
Domain 3: Professional knowledge
Domain 4: Capabilities in health promotion and illness prevention
Domain 5: Capabilities in leadership and team-working
Domain 6: Capabilities in patient safety and quality improvement
Domain 7: Capabilities in safeguarding vulnerable groups

At completion of ACCS a trainee will:

  • Know how to identify and reduce risks to themselves and other team members that arise whilst working in acute care
  • Understand the personal professional attributes of an effective acute care clinician
  • Be able to effectively manage their own clinical work load
  • Be able to deal with common challenging interactions in the workplace

At completion of training an EM specialist will:

Working with patients

  • Will be able to work effectively with patients who appear angry or distressed
  • Will have expert communication skills to negotiate complicated or troubling interactions

 Working with colleagues in the ED

  • Will be able to provide effective support to the ED team
  • Will understand the effect of stress and fatigue on the ED team
  • Will behave professionally in dealings with colleagues and team members within the ED

Working with others outside the ED

  • Will be able to work professionally and effectively with those outside the ED
  • Know how to safely deal with violent or threatening situations
  • Able to handle common but challenging situations:

– Self-discharge against advice

– Capacity assessment

– Adult safeguarding issue

– Police/FME enquiries

  • Aware of applicable national legislation and legal responsibilities, including safeguarding vulnerable groups
  • Behave in accordance with ethical and legal requirements
  • Demonstrate ability to offer apology or explanation when appropriate
  • Demonstrate ability to lead the clinical team in ensuring that medical legal factors are considered openly and consistently
  • Deal effectively with hospital colleagues when accepting clinical handover appears troublesome
  • Liaise effectively with primary care colleagues

Knowledge of applicable specific legislation:

  • Data Protection, GDPR
  • Information Governance,
  • Freedom of Information
  • Caldicott Report.
  • Mental Health,
  • Mental Capacity,
  • Children’s legislation.

Knowledge of the ethical and legal framework including issues relevant to:

  • Advance Directives
  • DNAR Decisions
  • Organ and Tissue Donation


  • Effectively communicate with members of the ED and external teams
  • Ability to make decisions pertaining to the appropriateness of resuscitation and ceiling of care, within an ethical and legal framework and communicate these effectively to relevant individuals.
  • Ability to judge issues of Safeguarding for adults and children.
  • Ability to assess capacity and obtain consent to treatment
  • Ability to resolve conflict
  • Ability to judge issues of confidentiality with respect to both the interests of the patient and the public
  • Able to recognise bullying, incivility and undermining and escalate concerns

Attitude and behaviour:

  • To behave at all times in a professional manner
  • Aware of own limitations and ability to ask for help as necessary
  • RCEM learning/ FOAM material
  • Formal teaching in ACCS will include material mapped to the key capabilities in this SLO.
  • Trainees will need to record their interaction with learning material and reflection that maps to the key capabilities
  • Departmental/ regional teaching mapped to the key capabilities in this SLO
  • Simulation based training of challenging encounters in the ED
  • Leadership training materials including RCEM leadership programme
  • Departmental/ regional teaching mapped to the key capabilities in this SLO
  • Simulation based training of challenging encounters in the ED
  • Leadership training materials including RCEM leadership programme

In core training it would be appropriate to seek feedback on dealing with challenging situations. This might include patients who appear distressed or angry. This must be done with senior staff able to maintain patient and trainees safety. Feedback and reflection on challenging interprofessional encounters would demonstrate the practical application of approaches and concepts developed in the programme of learning.

Suitable WPBAs include MSF, RCEM assessment App; Mini-cex; CBD; ACAT;

In intermediate training there is an expectation that any challenging encountered would be sought and feedback given. They also may be the subject for case based discussions. In this way the trainee will further develop their range of approaches to situations they will encounter as senior most clinician overnight. Trainees will be expected to gain a fuller insight of their tendencies to respond and reflect on effective approach for them as an individual.

Suitable WPBAs include MSF, RCEM assessment App; Mini-cex; CBD; ESLE.

In higher specialist training there is a greater complexity of situations that may arise that require a response, in readiness for consultant life. These may be discussed with trainers after the event, or observation and feedback may be invited if such scenarios arise at work when a consultant trainer is available to offer this.

Suitable WPBAs include the MSF, RCEM assessment app, CBD and ESLE.

Entrustment Decisions

End of core training level 2b :

At the end of core training a trainee should be entrusted to work effectively as a member of the acute care team, with appropriate personal professional attributes.

End of intermediate training level 3: 

At the end of intermediate training a trainee should be entrusted to deal with most challenging situations faced on the shop floor, with consultant support from home.

End of HST Level 4:

At the end of training an EM specialist will be entrusted to deal with any complex or challenging situation on the shop floor. This will be supported by a clear understanding of relevant medico legal considerations, and by advanced and effective communication skills.

RCEM examinations


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