By 
Our health system can work against our own personal self-care.
I’ve written about this previously
In fact, our health system can be a significant contributor that works against our own personal health and psychological well-being.
This isn’t because our system is uncaring or faceless or lacks purpose but rather it has been driven towards the wrong outcome — patients first at all cost.
And this cost has fallen against our health employees and is slowly taking its toll on all of us who work to serve the sick and the injured.
See the one thing that our health system has forgotten is that the health and well-being of our health employees are just as important as the patients that we look after.
Health employees, especially those providing clinical care are human beings too, who want to be seen (appreciated), safe (not pushed towards burnout by unrelenting work or toxic environments), and secure (with tenure, pay that matches inflation and care) in our work.
And here’s the problem that our health system faces — if our health workers are unwell, burnt out and depleted, they will not be able to care for others.
It’s simple, depleted workers cannot care for the sick and injured.
It’s impossible to drive towards patient outcomes with a depleted and burnt out workforce.
This is because we know that health workers who are overworked and burnt out are more likely to make mistakes and be absent from work. They are also more likely to create a toxic work environment which is a precursor to bullying and harassment.
In other words,
“We cannot care for others if our environment and system does not care about us”
This may be easy to summarise, however, it is much harder to action — our system needs to prioritise health workers’ wellbeing as much as it does patient and political outcomes.
This article is about how our health system can start to prioritise health-worker well-being, specifically the health and well-being of our doctors.
It isn’t about assigning blame but a piece of hope.
It has been written with the self-care and well-being of every health employee across Australia in mind.
And I’ll warn you, it’s epic and also my own opinion as a senior doctor working in the Australian health system.
Health system issues and potential solutions to improve health worker self-care
Here is a summary of the key points, explained in greater detail below.
The simple things matter the most
As leaders at every level of health care, doctors can make a change and difference today. The simplest measures can make all the difference in the lives of those around you.
Finishing on time, stopping for lunch, being paid fairly and correctly, using email appropriately and being kind — all of these are possible today. And the change of tone they create is a kinder and more collaborative environment.
During the pandemic, our entire health system changed its approach overnight. And in the same way, improving our system comes down to changing our attitude and dedication toward improving the well-being of our health workers.
We don’t need more resilient health workers. Administrators and legislators, stop saying this. It is disrespectful and out of touch.
We need a health system that values the well-being and health of its workers.
Attend to bullying and harassment in medicine like we actually care
The reason why harassment and bullying continue in medicine is that many pretend that it doesn’t exist and are too afraid to do anything. Whatever we walk past, we accept. And whatever we don’t say or call out, is never highlighted or acted upon.
Harassment and bullying within the medical hierarchy need to be called out and dealt with appropriately. There needs to be a clear and confidential pathway to report and penalties and dismissals for those who harass — clear and simple.
Not one of us in the medical profession has escaped the wrath of an insecure bully or witnessed or experienced harassment — it is, unfortunately, ubiquitous in medicine.
Promote psychological safety and assign accountability
Health leaders need to be accountable for the well-being of their healthcare staff.
Placing psychological safety as a key performance index will help to drive change within hospitals and health systems.
When your job is on the line, you’re less likely to be distracted by things that do not matter. This is already happening in one state in Australia. It is time for a national approach.
Let’s get real about tackling bullying in healthcare
Bullying is a symptom of organisation distress and dysfunction. However, this can be systematically addressed and bullying is preventable. Again it comes downs to the willingness of boards and executives to acknowledge this and drive change.
Medical, nursing and administrative bullies, certainly didn’t start out that way. They are a product of the system that never corrected them or created an environment that prompted them to think and act differently.
Place health worker well-being at the bottom line of every budget
Nothing changes in healthcare without appropriate funding — money.
The allocation of funding comes from having a clear strategy and an intention to place healthcare workers’ well-being as a priority.
Money buys expert time and resources that help to drive change. And we need these to help educate, administrate, implement and monitor our policies and programs.
Without funding, we are using hope as a strategy and as I tell my children, wishing upon a star.
The injection of more money and more staff may help for a season, but healthcare workers who are seen (appreciated), safe (psychologically) and secure (tenure of employment and tackling bullying) are ones who thrive.
This requires funding.
Make well-being and burnout prevention training mandatory for all staff
Tremendous emphasis is placed on training to improve patient outcomes. Yearly hand hygiene training is an example of this. However, if our staff are our most precious commodity, in that they perform the “health-caring”, yearly training must focus on keeping them mentally well and healthy.
All healthcare staff need to receive required and specific training on how to prevent and walk through burnout, attend to their own self-care and maintain their psychological well-being.
To change our culture and improve patient outcomes, equal emphasis needs to be placed on staff well-being and health outcomes too.
It is madness that such focus is placed on patient well-being at the expense of the most precious asset in the health system — health workers.
Ask yourself, how can depleted, unwell and burnt-out staff perform at their best?
They can’t. It simply isn’t possible.
It does not make sense to me that rational health administrators, executives and legislators still do not get this. And again, reach for the resilience lever.
Add staff health and well-being to our national accreditation standards
Our hospital is about to undergo accreditation and the flurry of activity in ensuring that every outcome which is being measured is being attended to is stunning.
Whatever is accredited is held to a higher standard and helps to drive change. Wherever there is a standard this helps to maintain a level of competency. Healthcare staff burnout and psychological health is a safety and quality issues as these directly affect patient outcomes.
Staff health and well-being is an equal and worthy National Health Care Standard.
A Royal Commission is the final act
A royal commission is a final act towards addressing any national and cultural problem that is harming our society.
A Royal Commission into the Medical Training, Culture and Workforce is not out of the question in my mind. In fact, it should be considered.
Now, let’s get into this!
Attend to bullying and harassment in medicine like we actually care
Do not touch and keep your mouth shut.
Whatever we walk past and whatever we choose to ignore, we condone and accept. We teach people how to treat us by what we defend and what we also keep silent about.
Bullying and harassment of all kinds are the hidden stains of medical training and workplace culture in Australia. Not one of us has gone through our medical training without experiencing the wrath of a bully or seeing or being subject to harassment.
The trouble is, that the gatekeepers through both bottlenecks of medical training and security of post-fellowship employment can also be the perpetrators.
There is no shortage of recent evidence that this is a major system issue and contributor to poor doctor well-being.
One-third of medical trainees in 2021 experienced bullying or harassment. And of these 67% did not report the incident and only half were satisfied with the outcome after reporting. This is damning and a clear source of system-related stress. My friend was right, no amount of personal self-care or resilience would combat this madness except for a few related things — evidence, courage and action.
The reasons for not-reporting are clear:
(1) Bad behaviour had become normalised
(2) There was encouragement not to report from senior staff, “he’s always been like that”.
(3) A lack of knowledge of how to report and escalate the issue
(4) There was fear of reprisal
(5) The potential fall-out and disengagement from the profession
(Llewellyn et al 2019).
I will admit that it takes a great deal of courage to inform, report and lodge a complaint about fellow medico. It is a strange barrier to cross likened to betrayal. Maybe I am being dramatic but as I reflect on my career and the handful of complaints and reports that I have made, mine have often stood alone.
Across the various hospitals and communities I have worked in, there has been rife gossip and clear knowledge that the doctor, nurse or administrator in question was incompetent, doing the wrong thing and was a bully, but it was never put in writing nor was it escalated. And so the victim list grew — both patients, doctors and nurses were burnt. Many left and have not returned.
A life’s ambition is ruined by a system not willing to change. And it was only after a significant tragedy unfolded or when everything was at a boiling point, that something was done.
There needs to be a clear pathway for reporting behavioural and sexual misconduct and in medicine.
AHPRA places a great focus on notifications of practitioner sexual misconduct towards patients, but we need a simple notification system for doctors to lodge notifications against other practitioners for bullying, harassment and misconduct.
Justice Kenneth Hayne who conducted the Financial Royal Commission has a suggestion that the medical profession should consider.
Justice Hayne suggests that for lawyers who bully and sexually harass in Australia, a system of fines and bans like that implemented in the United Kingdom should apply.
I wonder how this would look in our Australian medical system. And how the bullies and harassers in medicine would feel if they started to be named, receive fines and suspensions and were sidelined from practice due to their wretched and pitiful behaviour? I am sure that this would send a cold shiver down the backs of those in question.
And regarding the issue of reporting. One of the reasons that an offender collects a group of victims is because of silence. And in medicine and beyond, the common phrase is “I can’t”.
“I can’t report _____ because”, “I can’t say anything about _____ because”. And because is important as this is often tied to training progression, future opportunity and carving out a decent career and not being labelled as a “troublemaker”. This is perhaps one of the biggest impediments in our medical world. However, the issue here also lies beyond the victim-perpetrator relationship, as it involves those who are standing around and doing nothing. And in some ways, I think this is much worse because it allows evil to continue.
Respect and common human decency are at the heart of the issue. How can intelligent, hardworking and deeply ambitious people find themselves as either the perpetrator or victim or standing around?
Easy. For the perpetrator, it was behaviour that was not arrested when it started as a junior doctor or medical student. And now as a grown-up doctor, this behaviour is accepted because it produces what the health system and politics crave — efficiency and patient outcomes. And staff well-being and respect…..? Well, we won’t talk about that.
For victims and those caught in trying situations of bullying or harassment, the nightmare either has a countdown of days or a new personality type that they adopt each day to endure the abuse. Both of these are terribly challenging situations — an accumulation of trauma that is beyond the scope of this article. I acknowledge this, and would not be able to do this subject justice without further research. However, the strength of reporting is that it culls the number of victims but I recognise too, that it also comes with being labelled as “that person”.
Justice Hayne has an important message about respect that carries over to medicine too about how we who are shocked by this behaviour must respond.
‘Respect means if someone tells you they have been sexually harassed, listen. Listen carefully. Listen respectfully. Don’t shrug it off.’
As a senior doctor, I find that the part of the medicine that I practise nowadays has to do with navigating through people’s problems with each other.
And the greatest tool that I can employ is that of listening and acting appropriately, never dismissing or sweeping it away. Because if someone has taken time to talk to me, and been vulnerable with the details of the harassment and bullying that they have experienced, it is on me to do something. Leadership is action and clearing paths to allow our people to live and work at their creative and productive best.
Our medical culture rots when we stop listening and start caring and protecting ourselves more than the people we serve.
Mandatory reporting of harassment within medicine needs to be considered. This means that AHPRA needs to be clear about the standard of professional relationships that exist between doctors and everyone that they work with. And this might mean outlining the penalties for those who choose to breach these standards
In the medical world, the space between two doctors regardless of hierarchy needs to be clean and unambiguous. This is what medicine deserves. The rite of passage through medicine is a story that we tell to cover up bad behaviour, outdated practices, ingrained sexism and other cringe-worthy closet-like behaviour.
We focus a great deal on mandatory reporting of child sexual abuse and reporting the deviant actions of doctors towards patients. It’s time to start educating and promoting the clean space that must exist between medical professionals and create a clear pathway to report and prosecute from within our profession.
Simply waiting for a rotation to be over, ignoring malignant behaviour and advances, changing our patterns of interaction and keeping silent simply will not do. Bullying and harassment will always be the hidden stain and ugly secret of medicine for generations unless it dies with us.
Here are my suggestions:
Supervisors/registrars:
(1) Arrest bad behaviour early — call it out for what is: Racist, sexist, agist or simply a lack of respect. Do it. We teach people how to treat others by what we do and what we ignore. Doctors are leaders whether we like it or not. Lead by directing your juniors on the way to behave and conduct themselves. Toxic consultants started as medical students and interns perhaps a few bad habits — these were never addressed and look what happened.
(2) Demonstrate the type of behaviour you want to see in others. Call out harassment and step up to bullies. *Inside scoop — bullies are insecure people. Arrogance is front to cover their inadequacies and what they fear most. You have two options, find their weakness and exploit it ruthlessly (sorry mum!) or stand up to them and counter their logic with the truth. *I wouldn’t be saying this if I hadn’t done this myself*.
Medical colleges should annually report on:
(1) Rates of bullying and harassment within their training programs
(2) Rates of bullying and harassment within their craft group
(3) Action taken to alleviate and promote better behaviour (like the college of Surgeons undertook in 2016 after damning evidence of harassment)
(4) Rates of doctors suspended, charged, fined or banned from practice for bullying and harassment within the profession (not towards patients — we already have this)
Health services need to be granular in their approach — bullying and harassment are everyone’s business.
(1) Train ALL staff to recognise medical and nursing bullying and how to support and manage this
(2) Perform regular audits on bullying using a risk tool
(3) Provide clear and confidential methods away from the perpetrator of reporting bullying and harassment. Every orientation or new staff member should be told the details about how to report any bullying and harassment within their service.
Government:
(1) Acknowledge that bullying and harassment occur and that this is an adverse factor in medical training and within the profession
(2) Require that governing bodies report on bullying and harassment and show compliance for creating a safe workplace — audited yearly
(3) Arm governing bodies with the ability to suspend and fine doctors for bullying and harassment
And if we are truly serious and do not accept silence as a remedy and fairy tales about a “rite of passage” anymore, then we should see a change — a change in our psychological statistics of well-being, a change in cultural attitude and a generation of doctors who will not accept bullying and harassment as normal behaviour in medicine.
Promote psychological safety and assign accountability
Make health-care boards and executives accountable for the psychological safety of staff
One clear way to place the issue of burnout and well-being on every health executive’s mind is to assign it as a key performance indicator.
There was a damning report that was leaked to the media last year about our local hospital which caused a local storm. But the results were no surprise. Everyone who worked here could taste and feel that something wasn’t right.
What I noticed in our hospital was what countless other doctors around the country were witnessing and experiencing too — a decrease in staff well-being and an increase in rates of burnout and an exodus of doctors and nurses from the profession.
An Australian health system in crisis.
But what brought us here?
COVID-19 was simply a stress test that may have broken already weakened links. And this was weakened through years of patchwork political fixes, focusing on the wrong performance indicators and the big one, allowing bullying and political nastiness to run rife across all levels of health care. This created a name, shame and blame culture that produced a generation who knew how to “cover themselves” at the expense of others.
Is this really our health-care system in Australia in 2022?
If so, what can we do?
We need to focus on the right outcome measures to drive change and health worker well-being and psychological safety are one of the most important.
As I discussed in my first article whilst individual self-care is a professional responsibility of every healthcare worker, our healthcare system needs to reciprocate by placing healthcare workers’ well-being at the forefront of policy, spending, education and strategy — it cannot be one-sided.
Health care works when we provide equal both patient and staff care. This means if healthcare is heavily weighted and scrutinised against patient outcomes at all costs, healthcare workers pay the physical and mental costs — which translates to worsened patient outcomes.
Last year the government in South Australia created the first laws in Australia that held hospital boards accountable for the psychological safety of their staff.
That’s right, health care boards became responsible for their employee’s psychological well-being and safety!
This meant that hospitals were tasked with implementing programs that minimised fatigued and improved psychological well-being for all their staff. And to comply with this legislation, WorkSafe would audit hospitals annually against agreed indicators.
This is a wonderful start, as it places health-worker wellbeing as a key annually audited indicator. More than that, it focuses the hospital executive to drive better performance in this area, or it could be their job on the line!
The key to improving health worker wellbeing is focussing on one parameter and working towards continual improvement.
The specifics of the legislation for each hospital are listed below.
Ensure that the incorporated hospital
(i) promotes a healthy workforce culture for and among staff employed to work within the incorporated hospital; and
(ii) implements measures to provide for and promote the health, safety and wellbeing of those staff within the workplace (including the psychosocial health, safety and wellbeing of staff); and
(iii) implements policies issued by the Chief Executive on workforce health, safety and welfare (including policies on workforce harassment and bullying), so far as those policies apply to the incorporated hospital;
South Australia — (Health Care (Governance) Amendment Act 2021)
Let’s get real about tackling bullying in healthcare
Workplace bullying is an organisational problem, not an interpersonal one.
“The biggest myth about bullying is that it is an interpersonal problem. People tend to think of it as a personality problem or a toxic person. However, the evidence overwhelmingly shows that it is a product of the work environment and the systems at work.”
— Professor Michelle Tuckey (University of South Australia)
As an Intern at Tamworth, I worked with a stressed and overworked surgical registrar. He was a bully and was the product of a not-so-great system. He was seconded away from his family in Sydney and was quite literally a nightmare to work with. He was pleasant to me when our bosses were around, but when they left, he growled, swore, swatted my hands, and physically intimidated me. He wouldn’t answer his phone or messages nor would he help me when I asked. Desperate, I didn’t know what to do, so I went above him and told my consultant. He was both surprised and appalled and said, “leave it to me”.
It was over Christmas and this registrar was given leave and returned 2 weeks later a different man. He looked younger, like the stress he previously wore had aged him at least 10 years. His manner was different and he was never again a problem for the remaining part of my term.
As I reflect on this, I realise that my registrar was probably not a toxic man or someone with a personality problem — he was a product of the system and its issues working against him. Away from his family, operating relentlessly, with long lists of patients in the clinic and on the ward and being expected to work the weekends and nights — all took their toll. I found out later, that all my boss did was grant him his leave and provided cover for him over the holidays — exactly what he need, not reprimand, but kindness and firm guidance away from his bullying deviation.
I think this diagram brilliantly demonstrates the issues that my registrar and doctors everywhere face as precursors to workplace bullying.
Australia unfavourably leads amongst European countries with having the highest rates of bullying. Research shows that 9.7% of employees surveyed in Australia had been subject to bullying. Wow! But don’t despair, bullying can be addressed if it is acknowledged and not promoted sideways.
What the research shows is that bullying is a symptom of our organisational structures and systems. It is a product of multiple factors that can lead ordinary workers toward bullying behaviour. And bullying is often a lag indicator for things that have already gone wrong in an organisation.
The only way that we can change our health workplace in my generation is for our health executives and decision-makers not to take this personally or politically, but to simply acknowledge and address it.
And fortunately, there is research and work done that we can follow. Professor Tuckey and her team at the Centre of Workplace Excellence have developed a bullying risk audit tool which identifies modifiable areas that organisations can address.
Broadly these areas relate to:
(1) The way working hours are organised and scheduled — rostering, leave, breaks etc
(2) Work performance management — having clear roles, fair allocation of tasks, rewarding and recognising performance and managing underperformance
(3) Relationships in the work environment — Individual and team interactions, good mental health culture and a safe working environment
I am certainly not an expert in bullying but rather a doctor who notices his environment, reflects continuously and seeks change for the better.
My suggestion to policy and decision-makers, health executives and legislators is simple — address bullying by focussing on prevention. And by doing so, you will help doctors and health workers provide better care for patients by reducing the system issues that work against their wellbeing.
Again, this isn’t personal and I am not pointing fingers at anyone, I simply desire change.
Bullying is a product of poor working environments. So whilst we do need to address toxic individual behaviour, we must focus our best attention on prevention. The best way to start is to audit what is happening at the moment and make the appropriate changes.
Place health worker well-being at the bottom line of every health budget
Allocate yearly funding towards health worker wellbeing.
“Despite the staggering prevalence of physician burnout and increased organizational awareness of the problem, many organizations have failed to take action commensurate with the risk to the organization”
(Shanafelt et al 2017)
There is clear evidence that medical staff burnout and distress affect patient care, however, there has been very little done or spent to address this.
Think about the last time that you heard about an initiative that helps to drive health employee well-being or health. They are likely few and often forgotten as the year and term roll on.
The number one thing that all health jurisdictions can do to improve health worker wellbeing is to please this as a line item on their budgets and thus incorporate this into their strategic plans.
The business case for placing health workers’ well-being in the health care budget is well-established as can potentially lead to:
- The decreased operational costs associated with doctor turnover
- Improved productivity of medical staff
- Improved patient safety, quality and satisfaction (Shanafelt et al 2017)
- Improved leadership ability from senior medical staff (Shanafelt et al 2020)
An interesting article by Shanafelt et al showed that improving the well-being and self-care practices of senior doctors, improves their leadership skills and the well-being of those working for them.
This is a power move and places clinical staff-wellbeing as a dimension of leadership growth rather than simply within the individual self-care space.
The future of health care in Australia lies in improving health-worker wellbeing.
Improving doctor and health-worker well-being comes with a cost but this is a strategic move from the hospital’s bottom line to improve patient outcomes.
This is challenging for health administrators, executives and legislators because it shifts funding from patient care toward staff health.
But one truth remains:
“We cannot care for others if our environment and system does not care about us”
This isn’t groundbreaking but a large cultural shift in the way that healthcare funds important initiatives.
Health executives can relax, as the literature does talk about wellness retreats, weekly yoga or exercise classes, stopping for hospital-wide mindfulness and a special vegan option in the cafeteria, but graduated and strategic moves.
Shanafelt et al and the team at Stanford Well MD centre have produced this wonderful diagram to show the potential evolution of a well-being focus of an organisation.
Where do you think your hospital or organisation fits on this spectrum?
For most of us, it may be at the novice or beginner level — awareness and maybe committee, we all have something to learn and implement here.
Here are two power moves that have the potential to change the well-being culture of our hospitals and health systems.
Power move #1 — Employ, equip and empower Chief Wellness Officers
True Australian health system transformation will begin when a Chief Wellness Officer is appointed across each health service — this is the future of healthcare.
Healthy staff = better patient outcomes
Dr Bethan Richards has had the honour of being appointed the first Chief Wellness Officer in Australia. And this is significant because it shows a health system that has connected improving staff well-being to improved patient outcomes. More than that it takes dedicated funding, a team and a systematic approach to improve health workers’ mental health and well-being.
(The Evolving Role of the Chief Wellbeing Officer — Lessons from the Pandemic — New England Journal of Medicine May 2021)
The future of healthcare is not about chasing improved patient outcomes but rather having a workforce that is healthy and thus ready, willing and able to care.
Power move #2 — Employ Chaplains (Spiritual and Wellbeing Officers) for staff care
Chaplains have a role to play in hospitals — not for the patients but for staff. This is a controversial suggestion in 2022 in the setting of our nation’s continual decrease in religious affiliation (ABS 2017). Although the first hospitals and modern hospital system have their origins in religious and Christian groups respectively, the role of the Hospital Chaplain has fallen out of favour.
I acknowledge the resistance as a Christian doctor and not secretly planning to proselytise my colleagues. However, I would suggest to you that Chaplains of any faith can play an essential support role for the staff of any hospital.
Chaplains provide pastoral care which is emotional, psychological and spiritual support. Pastoral care is now a term widely used in several job descriptions as it is an essential skill in supporting those in front-line and high-risk occupations. Chaplains provide support during major life transitions, and after traumatic events and can simply lend an ear to listen and counsel those experiencing grief and distress.
Doesn’t this sound like the cases, patients, families and situations we face each day as doctors?
Chaplains or “Padres” have played an essential role in our ANZAC traditions for over a century and supported our soldiers during all our significant campaigns. Closer to home Chaplains have a role in our school and funding has been recently extended with the job role expanded away from religious affiliations.
And in the corporate world, Fortesque Metals have employed workplace Chaplains to provide support to its FIFO workforce. This was in response to unacceptably high rates of mental illness, family and domestic violence, suicide and drug use. And results as studied by Murdoch University have been so favourable that the program has been extended, expanded and made permanent.
At Royal Perth Hospital, the Centre for Wellbeing and Sustainable Practice has been making an impact. Starting with supporting junior doctors and nurses, the program has shown promise and is something that can be replicated across every major hospital in Australia. Here Chaplains have been more favourably called “Spiritual and Wellbeing Officers” and have been essential members of supporting the junior medical officers.
Chaplains need to be a part of our healthcare team to provide on-the-ground well-being and moral support to our healthcare staff. Employing chaplains is a power move towards staff-care and thus better patient care. It isn’t about religion, but rather about lending an all-listening ear to those who need it — and we all do at some point.
Make well-being and burnout prevention training mandatory for all staff
Like hand hygiene and mandatory reporting, mental health education and stress and burnout training need to be mandatory for all staff working in health care.
If you are rolling your eyes, then you are part of the problem.
Hand-washing, mandatory reporting, fire safety and basic life support training all relate to patient care. There needs to be a reciprocal focus on health-worker health and well-being as we are the ones who perform the “care” in health.
Stop for a moment. If you do not think stress, suicide, burnout and depression are the dark and associated parts and consequences of healthcare, then you are standing at the nucleus of the issue — blissful ignorance, dare I say stupidity. And like I have taught my sons, “hope is not a strategy”.
Australia can be effective when it wants to. In the wake of the Port Arthur massacre, John Howard brought sweeping gun policy reform. New Zealand did the same thing after the Christchurch Mosque shootings. And a Royal Commission was called after Four Corners showed the shocking conditions Juvenille inmates in the Northern Territory were subjected to.
In the same way, we cannot ignore that working in healthcare is inert and without mental and psychological impact. Right now, we are standing on the cliff of the greatest healthcare worker walkout in history. Action needs to happen now.
Each craft group in health care — administration, patient service officers, doctors, nurses, allied health and health executive need specific and mandatory, but similar overarching education about the stressors related to health care provision and their management.
This meta-analysis showed that an organisational-wide approach is more effective in reducing burnout than individual doctor practices. The authors aptly summarise what our health-system approach should be to burnout —
“If burnout is a problem of whole health care systems, it is less likely to be effectively minimized by solely intervening at the individual level. It requires an organization-embedded approach” (Panagioti et al 2017)
In other words, no amount of doctor mindfulness, exercise and resilience training can mitigate an uncaring and punitive system. Again, common sense.
The Grattan Institute suggests our current model of burnout prevention focuses too heavily on the individual, often blaming the victim (likely for a lack of self-care). Their commentary refocuses our attention on the fact that hospitals can reduce burnout by caring for their staff after stressful events and providing training in burnout prevention strategies.
All staff need to be informed and trained about stress and burnout in health care. Policy needs to direct managers and executives towards reporting on a well-being index and psychological safety. And legislators need the perspective that health-caring is not inert and without psychological and social consequences.
Again, this statement encapsulates what needs to happen to help prevent burnout.
“If there was a training course that could halve healthcare workers’ odds of harming patients, it would be made mandatory.
Prevention of burnout should be treated with the same urgency by governments and all health sector employers” —
Stephen Duckett & Edward Meehan — Grattan Institute
I acknowledge that staff shortages are the most acute issue that we face, but a wide approach is needed for long-term change, not simply finding more “health-caring bodies”.
Mental health and burnout prevention training needs to be mandatory across our healthcare systems for medical and non-medical staff. And like our handwashing modules, these are to be completed regularly!
Add staff well-being and health to our national accreditation standards
Health staff burnout and stress is a safety and quality issue
Whatever we are measured against becomes the standard and our focus. And whatever is optional and “nice” is often forgotten when the crisis is over. Such is the case with staff health, burnout, bullying and health worker mental health.
There is no mention in our National accreditation guidelines about staff health and wellbeing. The word “wellbeing’ appears 8 times and only relates to patient care. However a search of the term “burnout” returned some promising results as this appears to be on the agency’s radar as a safety and quality issue.
There is a growing evidence base that burnout and reduced staff well-being are contributors to reduced quality of patient care. This recent study by Hodkinson et al published in the British Medical Journal, highlights this clear association
If our legislators, health executives and those who regulate our hospitals are serious about changing the culture of our hospitals and healthcare provision, then our quality standards must change.
Adding a “Staff Health and Wellbeing Standard” is one national strategy toward change within our Australian healthcare system.
With one standard, we can potentially bring awareness and action towards staff health and wellbeing.
That is, all hospitals and health networks that require national accreditation for funding will need to meet certain standards for the provision of training, ongoing monitoring and policies that support staff wellbeing on all levels.
More than that, they will need to show meaningful policies and programs for the prevention of bullying through audit and action. Mental health education and support for all staff and all levels. And finally, continual monitoring of the cultural pulse through wellbeing-index and psychological safety measurement.
Here is my attempt at writing a Health and Wellbeing Standard:
Have big dreams, right?
I don’t think this will solve every system issue, but better staff care and health have to be a quality and safety factor — we already have evidence of this.
A Royal Commission is the final act
The final act in Australia for declaring a cultural emergency and the acknowledgement of acute change amongst widespread systemic problems is a Royal Commission.
Perhaps the shocking truth of doctor suicide needs to hit close to home for an important person or for the doctor and nurse shortage to bring forth a country-wide epidemic of medical mistakes due to staffing crises and widespread burnout. Or perhaps a provocative Four Corners special needs to shed light on the shocking truth. Something will happen, I am sure of it.
A Royal Commission into the Medical Training, Culture and Workforce is not out of the question in my mind.
We are already at that point.
The simple things matter the most
I will finish this piece with a reflection on what simple measures can make the biggest difference in a doctor’s life.
Being physically well, emotionally supported, psychologically safe and spiritual unbroken should be our medical blue sky. And this should be the “normal” that we work towards in our medical generation.
But here are a few things we can start doing today:
Say thank you and mean it. Say thank you to the Resident Doctor who came and placed that IV for you or to the registrar who helped solve your problem. Say thank you to your GP for seeing you and say thank your nurses and doctors who are at the front line. Say thank you to your staff and say thank you to your team each day. A heartfelt thank you with eye contact coveys an appreciated connection. Let’s cultivate an attitude of gratitude for our world-class health system. This is because gratitude begets more gratitude.
Be kind. It feels good to do good. And it feels good to be appreciated!
We help ourselves when we are kind and brew natural physiological goodness that bathes and soothes our brains with a warm oxytocin glow.
More specifically, our kindness needs to be granular — that is we all need to look out for each other and concern ourselves when a colleague or fellow health worker is suffering. A doctor or a nurse committing suicide in the next town over affects all the doctors and nurses in the towns that surround it and beyond. And to a degree, it affects all our non-medical support staff too — this is the effect of reciprocal suffering. The loss of one affects many.
To practice kindness on a granular level is to do so in every moment and for kindness to infuse each decision that we make. It is to understand that what our health system needs now is not more silo-like behaviour but for us as a group to help each other through whatever storm lies ahead.
Finishing on time. If you are the boss or in charge, make sure your junior doctors or staff finish on time. As I mentioned “rites of passage” are false stories that we tell to appease injustice, accept bad behaviour and promote poor practice habits. Help your staff finish on time by improving their skill and efficiency. And if you need to, help your juniors finish their work! Nothing should be beneath you — humble and confident wins over brash and boastful every time.
Stop and eat. Finishing on time and stopping for lunch or morning tea is important. More than that, if you can step out into the fresh air and sun, it provides space during the day to breathe and feel like the day has another chapter. The benefit from roasting your face in the warm winter sun holds great benefits for the rest of your day.
Pay over time and do not delay. Money is a symbol of trust and appreciation that is earnt from time spent solving problems and providing a service. The greatest injustice in a junior and training doctor’s world is not being paid for work completed. It is disrespectful and confers an unappreciative and dismissive attitude. If there is work that has been done, pay for it and pay for it now. Delaying payment increases resentment and cultivates an atmosphere of toxicity that thrives.
Stop using email as a weapon. Administrators, managers and senior staff listen up, there is a right and wrong way to use email.
Let’s talk about what should be done — phone calls over email. A far better way to cultivate a personal connection (which is lacking as we get busier) is to make a phone call. This is especially true if you have questions to ask or need input to solve a problem.
This article articulates the problem with email well as (1) Most of us struggle to get the emotional intelligence right in emails (2) Email promotes reactive responses rather than measured thoughts (3) Email prolongs the debate with both parties or more takes longer to reach consensus or a decision.
But by far the greatest pitfall of email is the weaponised passive-aggressiveness of inappropriate copying and escalation. In my case, what could have been solved with a phone received both an inappropriate escalation and several other people invited into the issue. Copying multiple people who aren’t involved is a bullying tactic, a passive-aggressive way of making a point. This brilliant article and study by David Cremer further demonstrate that cc’ing inappropriate or multiple people into an individual communication decreases trust between managers and employees and between coworkers. Pick up the phone and stop cc’ing multiple people into your email to “cover yourself”. This decreases trust in you, my friend. Stop it.
And just like that, you’ve practically and rapidly improved the well-being of your medical staff without resorting to the nonsense of resilience training.
The bonus suggestion is to build trust
This is how you build trust as a leader at any level:
(1) Apologise — If you’ve done the wrong thing — apologise and do not repeat the mistake, it takes repetition for trust to be rebuilt
(2) Be competent — know your job and do it well. If you don’t know, then ask. Insecure people carry on and make larger mistakes.
(3) Compassion — Care about the people you manage and help them perform their work. Be mindful of their struggles and be their advocate.
(4) Character — We build a good character one wise decision at a time. So, if you are the leader, make honest decisions and repeat this over and over again. Wisdom is found in honest decision-making, not popular ones.
(5) Listen — Listen to your staff. Simply listen. Do not defend your position or feel like you have something to prove. You’ll be much more effective if you listen more than you talk.
And that is it.
Conclusion
This is an epic piece of hope in the midst of a crisis and these thoughts are exclusively my opinion and not that of my employer.
Caring about the carer needs our attention in health care. It is our new journey, the next step and the focus of generations to come.
We’ve been so reluctant to even think that spending money and time on our health workers is valuable, that we’ve become stuck.
Almost everything that we’ve done until now has driven us towards patient and political outcomes to our own detriment.
Caring for our health carers allows them to work at their best.
Piling on the work, removing resources, pushing unnecessary standards, being overly harsh in conversation and death-defyingly scary when a mistake is made has led to toxicity.
“We cannot care for others if our environment and system does not care about us”
Healthy doctors equal better patient care.
Healthy health-care workers equal exceptional patient care.
This is the way health care needs to work. But unfortunately, we sacrifice ourselves and our colleagues at the altar of patient work. That is why we are so unhappy and find little joy in our work — it’s a pay cheque instead of a meaningful contribution we happen to be paid for.
I love being a doctor and love working with an unbelievable team and will continue to write and advocate for health worker well-being and health.
Finally, this Tweet from Gavin Preston summarises what is wrong with health care. We are way too stuck in our ways to recognise the truth from tradition.
So please, no more resilience training. Seriously, no more.
Live intentionally.
Love relentlessly.
And enjoy your health!
Dr. Jonathan Ramachenderan
@drjonathanrama
The healthy GP 