Doctors' Welfare Guidelines

Second Edition: 26 June 2020

Purpose

These Doctors’ Welfare Guidelines are principally written for organisations that employ doctors. They are largely based on, and are consistent with, the Developing a workplace mental health strategy guide produced by Beyond Blue in August 2017. The main purpose of the guidelines are to improve the mental health and wellbeing of doctors. They were developed in response to extensive research that has found doctors have a higher level of psychological distress and suicidal ideation than the general population and other health professional groups. Doctors are at particular risk of stress-related conditions due to a range of factors, including the high level of responsibility of their work, competitive nature of their training and tenuous nature of their employment. Preventable factors, such as an unsupportive work environment, make this stress even worse. The level of doctors’ health and wellbeing, at organisational and individual levels, correlates with productivity and patient safety. It is therefore in the best interest of doctors, patients and health providers (for health organisations and individual work units/ departments) to create a ‘healthy workplace’ that minimises stress on individual doctors. There is clear evidence that doctors with mental health conditions, and to a lesser extent physical health conditions, are subject to high levels of stigma at all stages of their career. This stigma can not only create severe stress for individuals, it can also deter doctors from seeking appropriate treatment. Creating mentally-safe workplaces is important for everyone, as is addressing cultural issues which make it hard for doctors to seek help. While suicide is a devastating event, many of the contributing factors will be upstream of a suicide event. A focus on prevention and early intervention is important to address the growing burden of psychological ill health in the medical profession. An ‘integrated approach’ that focuses on promoting and protecting the wellbeing of doctors, and intervening to address mental health conditions is required. Doctors’ health and wellbeing is affected by issues at organisational, team and individual levels, therefore, a range of strategies need to be implemented at each of these levels.

Applicability

These guidelines are aimed at health organisations that employ doctors. However, the underlying Principles and many of the Doctors’ Welfare Plan strategies are also applicable to any other organisation where doctors work, including small solo practices, private hospitals with visiting doctors and large group practices. Organisations that want to improve the mental health and wellbeing of their doctors are welcome to adapt and use these guidelines. It is recommended that larger organisations develop a Doctors’ Welfare Plan following these guidelines as closely as possible. The principles should be adhered to wherever possible.

Principles

The principles underpinning mentally healthy workplaces for doctors are:

GOOD PEOPLE MANAGEMENT AND ADDRESSING PSYCHOSOCIAL HAZARDS:

  • All doctors have the right to feel physically and emotionally safe. Doctors are human and are subject to the same physical and mental health conditions as the general population.
  • Work culture, practices and supports are often more important factors in determining the level of an individual’s stress than their own personal resilience.
  •  Professional and workplace culture for doctors should be nurturing and should model the principles applied to patient-centred care.
  • Health organisations should be respectful to all doctors in their policies and management practices.
  • Bullying and harassment of doctors is endemic in many medical organisations and departments. Persons and environments that are inherently dangerous or toxic should be identified and removed.
  • The same fundamental rights of workers in any profession also apply to doctors. In particular, doctors should have access to leave and, where possible, to part-time work. Rostered working hours should reflect actual working hours and all legitimate claims to unrostered overtime paid.

PROMOTE WELLBEING AND REDUCE STIGMA:

  • The medical professional ideals of perfectionism, toughness in the face of adversity and ability to keep going no matter what, need to be challenged.
  • Stigma is a major factor leading to doctor stress and suicide, and deterring doctors from seeking appropriate treatment of mental health conditions.
  • Mental health conditions need to be ‘normalised’, and viewed and managed by the workplace in a constructive way, similar to how physical health conditions are.

EARLY RECOGNITION AND SUPPORT:

  • Doctors should be encouraged to have a GP and not self-manage themselves.
  • Doctors should be encouraged to disclose health conditions that may affect their ability to work and be assisted with finding appropriate management for their condition.
  • Doctors in difficulty need a safe point of first contact, with the option of someone independent from their employer and supervisor.
  • Barriers to doctors accessing support within the organisation must be identified and controlled. The control measures should be monitored and regularly reviewed.

MITIGATING THE CONSEQUENCES OF ILLNESS

  • Where possible, doctors with health conditions should be supported at work and with return to work from illness, including flexible part-time options.

Infrastructure requirements

Each health service/organisation should have the following strategies in place to support doctors’ welfare:

DOCTORS’ WELFARE PLAN

Every organisation that employs doctors should have a Doctors’ Welfare Plan.

SENIOR MANAGEMENT (EXECUTIVE) SUPPORT

Senior management support is essential for the success of any organisation’s Doctors’ Welfare Plan. The Doctors’ Welfare Plan and associated infrastructure must be endorsed, supported and adequately resourced by senior management.

DOCTORS’ WELFARE STEERING COMMITTEE

Organisations should establish a Doctors’ Welfare Steering Committee with Executive (or Principal) sponsorship to oversee strategy development and the implementation of the Doctors’ Welfare Plan.

  • The committee should include representatives from Medical Executive, Medical Education, Medical Workforce and Occupational Health and Safety.
  • Both junior and senior doctors should be represented on the Doctors’ Welfare Steering Committee, or a subcommittee thereof, and have a strong voice in its deliberations. All elements of the Doctors’ Welfare Plan should have the support and endorsement of both junior and senior doctor groups. Health organisation Executives and Boards must be informed about elements of a Doctors’ Welfare Plan that are not supported by the junior or senior doctor representatives.
  • Doctors with a ‘lived’ experience of a mental health condition should be represented on doctor groups.

RESOURCES

Sufficient resources must be provided to develop and implement the Doctors’ Welfare Plan.

CONFIDENTIALITY

The confidentiality of doctors’ health problems must be maintained. Staff working with individual doctors should only be informed of their specific health issues with the consent of the doctor. All collected data on doctors’ health should be aggregated and de-identified.

MONITOR

The Doctors’ Welfare Steering Committee should monitor the level of doctors’ satisfaction and wellbeing at all levels, on at least an annual basis.

REPORT

Items regarding doctors’ welfare, including the level of satisfaction and wellbeing, should be discussed at Executive level at least monthly and at Board meetings six-monthly.

REVIEW

The Doctors’ Welfare Plan should be reviewed at least annually.


Doctors’ Welfare Plan

The Doctors’ Welfare Steering Committee should analyse its organisation regarding doctors’ welfare needs, identify priorities, and then develop and implement a Doctors’ Welfare Plan. The plan should include strategies at organisational, departmental and individual levels that:

RAISE AWARENESS

  • Regularly provide information about mental health and wellbeing to doctors through multiple channels, including suicide risk, self-care advice, positive coping strategies, resilience and when to seek help.
  • Ensure staff are aware of their roles and responsibilities regarding mental health in the workplace, including legal obligations.
  • Promote events such as Australian Mental Health Week, R U OK day, Crazysocs4docs day.
  • Recognise the important relationship between work and home life.

ADDRESS IDENTIFIED HIGH RISK GROUPS

  • Target interventions at groups of doctors considered at high risk, for example, interns, doctors sitting exams and International Medical Graduates (IMGs).
  • Monitor risks and consult with doctors in these highrisk groups to develop solutions.
  • Assist doctors going through professional transitions, for example, resident to registrar and registrar to consultant.

FOSTER AN ANTI-BULLYING AND HARASSMENT CULTURE

  • Create greater awareness of bullying and inappropriate behaviours.
  • Educate staff and managers about appropriate and inappropriate behaviours.
  • Create or improve policies and protocols around workplace bullying, setting a zero-tolerance approach.
  • Implement confidential reporting and response procedures for when bullying occurs; treating all matters seriously. Ensure policies and procedures protect anyone who reports or witnesses workplace bullying from victimisation.
  •  Liaise with supervisors, other workplaces, training programs and colleges as appropriate, regarding individuals identified as engaging in ongoing bullying or harassment of a serious nature

PROMOTE POSITIVE MENTAL HEALTH AND WELLBEING

  • Senior doctors and organisational leaders should model good wellbeing behaviour.
  • Encourage all doctors to have a GP and have regular check-ups.
  • Discourage doctors from prescribing for or treating themselves or work colleagues (unless in a formal doctor-patient relationship)
  • Provide training and development to doctors at all levels on positive proactive leadership, including; providing constructive feedback; supporting employee growth; praising efforts as well as results; and where possible n meeting individual learning needs.
  • Encourage doctors to work as a team with other doctors (at all levels) and non-medical staff. Where appropriate, take part in social activities.
  • Regularly collect feedback between those being supervised and supervisors.
  • Create opportunities for medical staff to have input into how the wider organisation is run and how their feedback is being used for improvement.
  • Promote healthy living, for example:
  1. Healthy eating
  2. Exercise
  3. Smoking cessation
  4. Responsible use of alcohol
  5. Avoidance/reduction in recreational drug use
  • Encourage activities that individuals find stress relieving, such as mindfulness.

COMBAT STIGMA

  • Persons with a personal experience of recovery and management of a mental health condition should be invited to share their story in the workplace, for example, at a Grand Round or in a workplace publication.
  • Encourage senior doctors, including Executive, to speak openly about mental health in the workplace by actively endorsing and participating in activities and events aimed at reducing stigma.
  • Promote zero tolerance for discrimination against staff who have a mental health condition.
  • Support staff with mental health conditions to stay at work or return to work, by making reasonable adjustments.
  • Provide information about resources that challenge inaccurate stereotypes about suicide and mental health conditions.

SUPPORT DOCTORS WITH MENTAL HEALTH CONDITIONS REGARDLESS OF CAUSE

  • Develop the capabilities of supervisors regarding identifying staff at risk and supporting those with mental health conditions.
  • Provide a range of internal and external mental health support options, for example, internal ‘safe’ point of first contact and external employee assistance programs. Stipulate confidentiality and make the pathway for accessing support clear.
  • Breakdown the misconception about the process and requirements of the mandatory reporting requirement to the Medical Board of Australia, under State law.
  • Where possible, provide flexibility regarding work hours and tasks, and prioritise mental health and wellbeing above performance expectations.

SUPPORT RETURN TO WORK AFTER ILLNESS

  • Develop policies and procedures relating to return to work plans, or additional support when at work, for doctors who have been diagnosed with a physical or mental health condition. Where possible, the same level of support should be offered to those with work or non-work related health conditions.
  • There should be a designated person (position) who is responsible for return to work programs for doctors. The program for individual doctors must be agreed to by the doctor and relevant supervisors informed of the plan. Where appropriate, other relevant staff may be informed of aspects of the plan if the doctor consents.
  • The doctor must have a designated person who is responsible for overseeing and monitoring an individual return to work plan, has regular contact with the doctor, and is the first point of contact for the doctor if any issues arise.

PREVENT SUICIDE

  • Invite people with a personal experience of recovery related to suicide to share their stories in the workplace. Ensure appropriate supports are available to the speaker and others who may be affected by their story.
  • Develop clear protocols around suicide and suicidal risk.
  • Provide additional support to staff bereaved by the suicide of a colleague, family members, close friends or patients.
  • Educate doctors on how to recognise risk of suicide/ severe mental health distress in colleagues, how to approach these colleagues and what resources are available to help them and their colleagues in this situation.

IMPLEMENT GOOD MEDICAL EMPLOYMENT PRACTICES

  • Units/departments should be adequately staffed at senior and junior doctor levels to reasonably cope with workload and internally cover leave where required.
  • Rostered working hours should reflect actual working hours.
  • Doctors should not be discouraged or intimidated from claiming legitimate unrostered overtime. All such requests should be paid.
  • Sufficient leave cover should be available so all reasonably foreseeable requests for leave (including annual, professional development and sick leave) can be covered.
  • Part-time work options should be available for all levels of staff.

IMPLEMENT GOOD MANAGEMENT PRACTICES THAT ENCOURAGE DOCTOR ENGAGEMENT

  • Doctors should be encouraged to form groups that can represent their opinions, assist with the planning of services and advise on changes.
  • Regular meetings of Executive members and junior doctor representatives should be scheduled to discuss matters of common interest.
  • Regular meetings of Executive members and senior doctor representatives should be scheduled to discuss matters of common interest.
  • Junior and senior representatives should be consulted prospectively on changes impacting their work design or work practices.
  • Executive members should be ‘visible’ and approachable to doctors at the workface.
  • A quiet, safe area away from clinical areas where doctors can meet and support each other, debrief, and vent issues in private should be provided.
  •  Communication to doctors at all levels should be respectful and understanding of their particular needs and circumstances.
  • Heads of Department and Medical Co-Directors should be adequately supported for their nonclinical role and be trained in doctors’ welfare.

ENCOURAGE INDIVIDUAL AND PEER GROUP SUPPORT AND DEBRIEFING

  • All doctors should be trained on how to recognise a colleague who may be distressed or have mental health issues, and how to ask them if they are OK.
  • Health services should have designated welfare officers (medical or non-medical) who are trained in addressing welfare concerns of doctors. They should be seen as ‘safe’ people to talk to and not be their supervisors (should not be someone who makes decisions on whether a doctor ‘passes’ a term or on matters relating to their ongoing employment).
  • Peer support groups should be encouraged and, where possible, facilitated by trained facilitators.
  • The health service should have guidelines and processes for critical incident support of doctors at organisation, departmental and work unit levels, for example, ‘Code Lavender’.

HAVE A PLANNED RESPONSE FOR THE DEATH OF A DOCTOR

  • The health service should have a protocol to be followed in the case of a doctor’s death. This should include how to inform staff of the death, offer them support and follow up (including information on crisis care resources inside and outside the health service) and provide guidance on how to express bereavement, for example, dedication morning tea and cards to relatives.
  • The health service should gather information regarding the circumstances of the death. For doctor suicides there should be a confidential internal investigation as to whether the hospital could have done anything to help prevent the death, with the Doctors’ Welfare Steering Committee and Board informed of the findings.

References

Developing a workplace mental health strategy. Beyond Blue, August 2017 https://resources.beyondblue.org.au/prism/file?token=BL/1728

Creating a Mentally Healthy Workplace, Return on Investment Analysis. Price Waterhouse Cooper for Beyond Blue, March 2014. https://resources.beyondblue.org.au/prism/file?token=BL/1278

Review of Safety and Quality in the WA Heath System – A strategy for continuous improvement. Department of Health Western Australia, July 2017 https://ww2.health.wa.gov.au/Improving-WA-Health/Safety-and-quality-review

Healthcare staff wellbeing, burnout, and patient safety: a systematic review. Hall LH, Johnson J, Watt I, Tsipa A, O’Connor DB. PloS one. 2016 Jul 8;11(7):e0159015.

Scheepers RA, Boerebach BC, Arah OA, Heineman MJ, Lombarts KM. A systematic review of the impact of physicians’ occupational well-being on the quality of patient care. International journal of behavioral medicine. 2015 Dec 1;22(6):683-98.

National Mental Health Survey of Doctors and Medical Students. Beyond Blue, October 2013 https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report—nmhdmssfull-report_web

The Mental Health of Doctors – A systematic literature review. Beyond Blue, August 2010. https://resources.beyondblue.org.au/prism/file?token=BL/0824

National Forum on Reducing the Risk of Suicide in the Medical Profession, High Level Summary. 14 September 2017, NSW Parliament House, Sydney.

Review of the morale and engagement of clinical staff at Princess Margaret Hospital. Department of Health Western Australia, May 2017. https://ww2.health.wa.gov.au/-/media/Files/Corporate/Reports-and-publications/PMH/Attachment-BPMH-Review-Final-Report-Signed.pdf

JMO Wellbeing and Support Plan. NSW Health. November 2017. http://www.health.nsw.gov.au/workforce/culture/Publications/jmo-support-plan.pdf

Creating Mentally Healthy Workplaces, a review of the literature. The Mentally Healthy Workplace Alliance. November 2014. http://www.blackdoginstitute.org.au/wp-content/uploads/2020/04/creating-mentally-healthyworkplaces.pdf

Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Shanafelt and Noseworthy. Mayo Clinic Proceedings. January 2017. https://www.mayoclinicproceedings.org/article/S0025-6196(16)30625-5/pdf