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Safety and wellbeing of psychiatrists and those in psychiatry training

Position statement Last updated: Feb 2023 Published in Australia Reference: PS #48

This position statement highlights the critical importance of the safety and wellbeing of psychiatrists and those in psychiatry training for competent and safe psychiatry practice.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises its role in supporting the psychiatry workforce. Consideration of safety and wellbeing must be prioritised in all decision making. A glossary of terms is available at the end of this Position Statement.

Key messages

  • Safety and wellbeing in the workplace is associated with safe and effective patient outcomes.
  • Bullying and harassment must be recognised, addressed and eliminated for workplaces to be safe. The RANZCP expects work and training environments to be free of bullying, harassment and discrimination. Psychiatrists and those in training, particularly those in leadership positions, are responsible for modelling professional behaviour and contributing to positive peer relationships.
  • While employers are responsible for the safety and wellbeing of their employees, the RANZCP has an important role in supporting and advocating for the health and wellbeing of psychiatrists and those in training, particularly in the course of administering RANZCP activities such as the Fellowship Pathways (training and SIMG).
  • Safe, healthy working environments must be implemented at individual, systemic and organisational levels.
  • Recognition and response is required for known safety and wellbeing issues such as for those in psychiatry training who face the stress of training and assessment, and for supporting psychiatrists and those in training who are culturally diverse.

Introduction

This Position Statement is relevant to all Fellows, Affiliates, trainees/Associates, and specialist international medical graduates (SIMGs), referred to in this document as ‘psychiatrists and those in psychiatry training’. If such groups are safe and well, they are better equipped to provide quality health services to the community.[1-5] 

Employers of psychiatrists and those in training are responsible for the safety and wellbeing of their employees under relevant workplace laws. The RANZCP has a role in advocating for safe, positive working environments that can be implemented at individual, organisational, and systemic levels.[4, 6] The RANZCP recognises its role in providing a safe and supportive training environment for psychiatrists and those in psychiatry training. We are accountable for RANZCP activities including administering the Fellowship Pathways (training and SIMG), and accrediting training programs and posts in psychiatry to ensure they provide quality training experiences that facilitate the training of safe and competent psychiatrists. 

The RANZCP is made up of individual members who are responsible for fostering safe and healthy working environments. Please see the RANZCP vision statement and supporting pillars for member wellbeing. 

Workforce wellbeing

Psychological wellbeing

Terms such as burnout, moral injury, and moral distress have been used to describe distress in clinicians.[7] This distress has been rising in the health workforce and addressing factors that cause or contribute to this distress is essential.[5, 8] 

Increased demand for access to mental health care services has resulted in workforce shortages, and these contribute to higher workloads and distress.[2, 5, 9] Shortages have resulted in instances of psychiatrists being directed to work outside their identified scope of practice and outside hospital credentialling. Workloads, time pressure, stressful environments, long working hours, poor resources, poor teamwork, a sense of lacking control, and incidences of discrimination, bullying and harassment are factors that contribute to burnout and adverse psychological outcomes, and are all either preventable or could be better managed.[2, 5, 10-14] These experiences are exacerbated in psychiatry subspecialties where there is a chronic paucity of resources, workforce, services, and infrastructure available to provide safe and adequate care. 

Burnout also affects workforce retention.[2] The 2020 RANZCP Member Wellbeing Survey found the highest-rated stressor was ‘too much work to do in limited time’.[14] Despite evidence that addressing burnout at an organisational level is cost-effective, this is rarely done.[10] It is important to prioritise prevention of burnout, moral injury and distress at an organisational level by implementing evidence-based strategies.[10, 12]

Repeated exposure to death, pain and suffering is a risk to clinician wellbeing.[11] Psychiatrists and those in psychiatry training are at a high risk of experiencing trauma and vicarious trauma.[15-17] Awareness of this risk, and trauma-informed approaches towards the workforce, are required at individual, organisational, and systemic levels.[15] Reflection, supportive supervision, positive, professional peer and mentoring relationships, and a work-life balance can all assist in mitigating the effects of vicarious trauma.[15]

Help seeking and stigma

Many people, including clinicians, experience mental health concerns at some point in their lives. Rightly, increasing attention is being given to the mental health of clinicians.[4, 18, 19] The RANZCP lists the promotion of physical health, mental health and welfare of psychiatrists and those in training as a key strategic objective.[20] For some clinicians, distress can lead to ideation, attempt, or completion of suicide, and high rates of anxiety and depression in comparison to the wider community.[11, 21, 22] Wellbeing surveys have found higher rates of psychological distress and attempted suicide in clinicians than the general population.[19] 

Stigmatising attitudes regarding the competence of clinicians who have a declared or known mental illness persist, in addition to the stigma associated with the psychiatry profession.[2, 4, 14, 19, 23] While the impact of stigma on people with mental illness and their families/whānau (a) is well recognised, the impact of stigma and self-stigma on psychiatrists and other members of the health workforce is not. Members of the health workforce receiving treatment for mental illness have reported stigma and discrimination by their employers and colleagues.[24, 25] The broader risks of self-disclosure in the workplace, and the real or feared impact of being considered an impaired practitioner are evident, with many concerned about the potential for discrimination, harassment, reduced career development opportunities, adverse reports to medical regulation authorities, investigation, medico-legal issues and deregistration. Barriers to help seeking, including fear of stigma, may be exacerbated in rural, regional, and remote areas. For these reasons, psychiatrists require discreet and confidential mental health services including psychotherapy.

The insights of clinicians with a lived experience can be a resource to improve the quality of mental health care, informing both clinical practice and service development.[24] Please see RANZCP Position Statement 85: The contribution to practice made by psychiatrists who have a personal experience of mental illness.

Diversity and wellbeing for the workforce

Culturally unsafe workplaces and discriminatory practices including racism affect workforce wellbeing, recruitment and retention.[6, 26, 27] Monitoring and reporting on cultural safety outcomes is key.[32] Please see RANZCP Position Statement 105: Cultural safety, which applies to all people across culturally and linguistically diverse communities, beliefs, values, ethnic groups, religion or faith, age, ability, sexual orientation and gender identity, and the intersectionality of these. In Australia and New Zealand, these considerations are particularly important for Aboriginal and Torres Strait Islander peoples and Māori respectively. The RANZCP is committed to fostering culturally safe environments.

The RANZCP values the expertise that culturally and linguistically diverse health practitioners bring to the workforce. The workforce should be representative of the community it serves. Further work is required to ensure that workplaces are culturally safe. The RANZCP recognises cultural loading, the additional ‘load’ that culturally diverse members of the health workforce bear, such as additional expectations and demands due to cultural identity e.g., educating others or tokenistic treatment.[28, 29] It is important to recognise cultural loading and provide support e.g., cultural supervision to assist health practitioners to review practices or respond to self-reflections.[30]

In academic, clinical leadership, speaking, and publication roles, female psychiatrists are under-represented.[31] Discrimination and gender disparities in relation to family planning has also been reported.[31] Workplaces must ensure sexual safety of staff. Please see the Australian Health Practitioner Regulation Agency and National Boards Position Statement: No place for sexism, sexual harassment, or violence in health care.

Considerations for cohorts

  • Those in training

Australia’s National Medical Workforce Strategy has noted that the health system is increasingly reliant on those in training.[6] In addition to being impacted by the same stressors as qualified psychiatrists, academic demands can add to stress and burnout.[4, 32] Those in medical training are also found to experience high rates of bullying and harassment.[33, 34] Between training, assessments, clinical responsibilities, overtime or after-hours commitments, and family/whānau or personal responsibilities, excess working hours may be more likely to occur at this time, resulting in fatigue and lower wellbeing.[4, 12, 13, 32, 35] 

Transitional periods, including transitioning out of training, are known to bring additional challenges and stressors.[2] When clinicians feel under-prepared, this impacts adversely on their wellbeing. Some reports have found that the majority of medical students experience feelings of ‘imposter syndrome’.[36] 

Reported concerns include feeling unappreciated in the workplace or neglected by supervisors.[32, 37] Supervisors report there are increasing demands on them for service delivery which impacts their capacity to provide appropriate and adequate supervision. Peer and supervisor support is important; networks facilitating peer support may assist.[32] Support and time for self-reflection and connection with others may assist psychiatrists facing issues of burnout.[2, 12] 

  • Private practitioners 

The RANZCP Section of Private Practice Psychiatry aims to identify and address issues concerning psychiatrists working in the private sector. Psychiatrists in the private sector may experience professional isolation from peers and supports that may be more easily available in larger organisations.[4, 38] Providing telepsychiatry services, despite the many benefits, may worsen this sense of isolation.[39] Opportunities for mentorship, peer review, and peer support such as Balint group (b) participation may reduce impacts and risks of professional isolation on quality assurance and wellbeing.[38, 40-42] Solo practitioners provide a valuable service, particularly in rural, regional and remote areas and should be supported to continue their work.[41]

Additionally, administrative demands are growing and can exacerbate experiences of stress and burnout.[41] The costs and pressures of running a business may be challenging.[38] Private practitioners may also have additional privacy and safety considerations when practicing from home or registering using a home address. Private practice psychiatrists should have safety measures in place for themselves, their staff and other patients.[43] 

  • Rural, regional, and remote practitioners (Australia)

Due to chronic workforce shortages in regional, rural and remote communities, workload pressures can be placed on psychiatrists, those in training and health services, exacerbating workforce retention issues.[44] Fewer clinical supports leads to increased responsibilities and requirements for a diverse range of expertise. It can be more difficult for psychiatrists in rural areas to collaborate with other clinicians due to distance and workload demands, which can result in professional isolation. Furthermore, they often have to assume multiple supervisory roles, but still maintain a heavy patient load. For more information on rural psychiatry challenges, please see Position Statement 65: Rural psychiatry.

  • SIMGs

SIMGS are vital in Australia and New Zealand, making up a significant portion of the psychiatry workforce, particularly in regional, rural and remote areas.[9, 45-47] In addition to the same challenges as other psychiatrists, SIMGs may experience discrimination including racism, challenges adapting to new systems, assessment pressures, visa complications, separation from family, complications bringing family over, adjusting to cultural differences, and sense of isolation.[14, 46-48] Workplaces have a responsibility to identify and address instances of discrimination. Transitional supports such as language, cultural, and other programs may help alleviate some of these challenges, as may mentorship and peer support programs.[32, 47] 

Safe, healthy workplaces

While impactful, it is important to acknowledge that individual interventions such as self-care practices are not the only level of intervention required to alleviate distress.[7] Accountability for strengthening health systems and providing safe, positive working environments needs to be addressed at organisational and systemic levels.[12]

1.    Safe workplaces free from discrimination, bullying, harassment, and violence

The RANZCP has a zero tolerance stance on bullying, harassment and discrimination and is committed to provided safe spaces within the RANZCP and RANZCP activities. Additionally, the RANZCP expects work and training environments to be free of bullying, harassment and discrimination. Please see the RANZCP Policy: Discrimination, Bullying and Harassment. The health and safety of the workforce must be prioritised via occupational health and safety measures and compliance with relevant local laws. This must include the provision of adequate pathways to report and address incidents of bullying and other unsafe work practices. 

Studies demonstrate that health care environments can be violent workplaces; staff are at risk of verbal and physical assault, bullying, and harassment from within the workforce, from patients and their families/whānau.[32, 42, 49] Experiences of workplace violence can cause physical and psychological harms, contributing to burnout.[50] Clinical settings must be designed and managed to prioritise safety, considering infrastructure, violence prevention and management policies, sufficient staffing, safety training, and incident analysis and support for employees.[51-53] In addition to these organisational safeguards, raising societal awareness about the importance of the medical workforce may assist in reducing violence.[50] 

2.    Positive team cultures

A positive team culture is experienced as feeling safe, encouraging, and comfortable for sharing experiences. Negative workplace cultures, including experiences of bullying or discrimination, are detrimental to wellbeing. 

Making adjustments to account for different work contexts, positive team cultures may be developed through:

  • Employing a ‘restorative justice’ approach to encourage a culture of reflection, learning, and accountability rather than resorting to blame and punitive measures.[54-57] ‘Blame’ culture is currently widespread in healthcare settings, where employees are blamed for errors which are inherent to the complex environment of healthcare.[57] Blame culture can arise from Safety I approaches, which focusses on investigation of errors and failures rather than Safety II approaches, which focusses on investigation of everyday successes to explain how occasional errors are made.[58, 59]
  • Investing in positive workplace relationships and team cohesion.[1] A sense of psychological safety at work allows healthcare professionals to engage effectively in their team by asking questions and making suggestions.[60-62] Positive relationships within teams with inclusive, open leadership models fosters this sense of psychological safety.[60, 61] Uncivil or exclusive behaviours threaten this sense of psychological safety, impacting quality of teamwork, patient care, and individual wellbeing.[63]
  • Providing opportunities for reflective practice to enable a learning culture, which is vital for behaviour change and effective teamwork.[64, 65]
  • Recognising that support is required for psychiatrists and those in training in response to workplace incidents, particular personal circumstances and other factors such as cultural load and location of practice.[3, 21]
  • Legitimising self-care as important and necessary for good medical practice, including addressing the stigma of help seeking for clinicians.[2, 8, 10, 21]
  • Addressing systemic issues with access to health care and workforce development.[3]
  • Prioritising workforce wellbeing and safety.[3] This may include providing access to Employee Assistance Programs (EAPs), peer supervision and peer review groups, mentoring, and evidence-based interventions to support the safety and wellbeing of psychiatrists and those in training.[8, 42]

3.    Positive, professional peer relationships

‘Having helpful colleagues’ was the highest-rated factor that assisted members when seeking support to maintain wellbeing via the 2020 RANZCP Member Wellbeing Survey.[14] ‘Lack of respect from administrators/employers, colleagues, or staff’ was reported by 32% of psychiatrists who responded in 2022, in comparison to 22% who reported ‘lack of respect from patients’, both of which were reported as contributing to burnout.[66] 

Supporting colleagues is important to prevent feelings of isolation.[4] The RANZCP Code of Ethics principle 9 states that ‘psychiatrists shall attend to their own health and wellbeing and that of their colleagues, trainees and students.’ This includes respectful, professional communication with peers in all environments including the workplace, within RANZCP and other professional activities, and over social media. Psychiatrists must lead with courage and compassion to influence workplace cultures to prioritise wellbeing by proactively advocating for each other. See positive team cultures and the RANZCP’s vision for member wellbeing leadership pillar.

4.    Supportive supervision and mentorship

Australia’s National Medical Workforce Strategy noted that regular, sufficient supervisor feedback was needed.[6] Principle 8 of the RANZCP Code of Ethics sets out that ‘Psychiatrists shall develop, maintain and share their professional knowledge and skills with colleagues, those in training, students, and with patients and their families/whānau.’ At all stages of a psychiatry career, access to appropriate mentoring, supervision and support is beneficial to both practice and wellbeing.[14] These resources can also assist in preventing burnout.[1, 10, 14, 67] Fostering career development, including development opportunities and support for personal goals can also reduce burnout.[2, 67] Mentors should receive training, and although it is ordinarily a voluntary role, professional time should be allotted to encourage mentoring within workplaces.[67]

The RANZCP has a role in promoting supportive supervision as an education provider, accrediting supervisors, and delivering the RANZCP Mentoring Program. Supervision can be a challenging responsibility, and supervisors should receive support for their roles, particularly in settings where these may be complex or conflicting with other roles. For more information on supervisor roles, responsibilities, and principles, please see the RANZCP supervisor resources.

5.    Work-life balance    

Work-life balance can be hard to achieve for doctors, and the RANZCP training has an impact on this balance.[6] Evidence has demonstrated that psychiatrist’s work-life balance has been worsened by the Coronavirus pandemic.[66] In addition to promoting self-care and wellness, it is necessary to implement measures which support the workforce to engage with the measures.[6] Addressing this gap will require that the health and wellbeing of workers is prioritised by monitoring staffing levels and screening for burnout in the workplace. In this regard, the 2020 RANZCP Member Wellbeing Survey found the biggest barrier to help-seeking was ‘time’.[14] 

The RANZCP has a role in creating and advocating for safe environments, including developing training principles and methods, and collaborating with members.

Workplaces can enable a positive work-life balance by: 

  • Providing flexible, family/whānau-friendly work options, and paid parental leave.[1, 2, 10, 12]
  • Maximising opportunities for career mobility and non-linear career pathways.[4]
  • Allowing sufficient time for both patient care and self-care.[10, 12, 14]
  • Improving teamwork and providing a supportive workplace culture.[10, 12]
  • Monitoring safety and wellbeing in the workplace.[10, 12]
  • Ensuring the conditions of employment attract, retain and support a healthy workforce including provision of calm working environments.[10-12]

Recommendations

The RANZCP recognises its role in advocating for and supporting the psychiatry workforce and acknowledges the importance of prioritising wellbeing in all decision making. 

The RANZCP recommends:

  • Supporting development and maintenance of healthy workplace culture for psychiatrists and those in training, including promoting psychological safety and eliminating bullying and harassment.
  • Advocating for well-resourced mental health systems, including safe staffing levels, safe overtime expectations, and recognition of the value and contribution of psychiatrists and those in training.
  • Addressing wellbeing issues impacting on psychiatrists and those in training such as burnout, moral injury and distress, and supporting effective organisational responses with evidence-based strategies.
  • Enacting the responsibility for psychiatrists and those in training to model professional behaviour, act in a way that improves everyone’s wellbeing, and contribute to positive professional peer relationships. In particular, those in leadership positions have a responsibility to lead with compassion and prioritise wellbeing.
  • Supporting psychiatrists and those in training to have well developed knowledge and skills in relation to their personal wellbeing and maintenance of a positive work-life balance.
  • Providing and advocating for appropriate support for culturally diverse psychiatrists and those in training for whom there may be additional load in the workplace and beyond it.
  • Promoting and improving the essential role of supervision, mentorship and peer review in maintaining wellbeing in psychiatry practice across all stages of a career in psychiatry.
  • Evaluating the wellbeing of psychiatrists and those in training; to support the aspiration of the RANZCP for healthy psychiatrists and those in training.

Available support

Further reading

Glossary 

  • Burnout is a common-language term which refers to a pattern of malaise, fatigue, frustration, cynicism, and inefficacy that arises from having experienced excessive demand on energy, strength, or resources in the workplace’.[7] Burnout is associated with medical errors and the delivery of poorer quality of patient care.[68] For more information please see the RANZCP document Keeping yourself well: Support and strategies to look after yourself and each other.
  •  Cultural safety
    • Australian Health Practitioners Regulation Agency definition: ‘Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism’.[69, 70]
    • Medical Council of New Zealand definition: ‘The need for doctors to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery. The commitment by individual doctors to acknowledge and address any of their own biases, attitudes, assumptions, stereotypes, prejudices, structures and characteristics that may affect the quality of care provided. The awareness that cultural safety encompasses a critical consciousness where healthcare professionals and healthcare organisations engage in ongoing self-reflection and self-awareness and hold themselves accountable for providing culturally safe care, as defined by the consumer and their communities’.[71]
  • Intersectionality theory highlights that systems can be discriminatory in multiple interrelating ways, including but not limited to, on the basis of gender, sexuality, class, age, race and disability.[72] This means that individuals can experience numerous forms of discrimination concurrently which can overlap and compound.[72]
  • Moral distress refers to the emotional and cognitive experience or response to a moral stressor.[73]
  • Moral injury is a concept frequently connected to burnout and referring to ‘trauma from adverse experiences that workers feel powerless to stop’. It may arise ‘where workers find it impossible to do what is ethically required’.[10]
  • Vicarious trauma refers to experiencing trauma through exposure to and compassion for the traumatic stories of others.[74]

Responsible committee: Member Wellbeing Subcommittee 

References

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Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.