Neobook — clinical reference

Personal responsibilities of the anaesthesia provider

Responsibilities toward healthcare workers, trainees and colleagues

Introduction

Many factors can contribute to the provider’s inability to function at their highest performance level, which ultimately impacts patient safety. These include work-related factors, organisational and health system-related factors, as well as personal factors: issues such as uncontrolled working hours resulting in excessive fatigue; workplace harassment and bullying; discrimination; stress; inadequate rest and nutrition while working; burnout; physical health, personal and mental health issues; substance abuse and addiction challenges.

The HPCSA Guidelines on Good Ethical Practice under “Duties to themselves” focus on the ethical duty of physicians and anaesthesia care providers to maintain sound professional knowledge and skills and good professional practice.

Sound clinical data over recent years have highlighted the need to prioritise physician health and wellness as well as knowledge and skills. The ethical responsibilities to promote and maintain the health of anaesthesia providers can be considered in three main areas:
(i) personal responsibilities,
(ii) institutional responsibilities, and
(iii) individual responsibilities towards other healthcare workers, trainees and colleagues.

All recommendations listed below are not comprehensive and not restricted to what is recommended.

Personal responsibilities of the anaesthesia provider

The ethical requirement to promote and maintain one’s own health and wellbeing must address all aspects of physical, mental and emotional health. As noted previously, there are many health and wellness challenges, and anaesthesia provision is particularly prone to stress in the workplace, excessive fatigue and higher risks of isolation, addictions and suicide.

Like everyone else, anaesthesia providers inevitably get older, bringing on a diminution of physical, mental and special sensory faculties. This may be counterbalanced to some degree by the wisdom that comes with experience. There is also much variation between individuals in the ageing process, not only in the degree of functional impairment with age but also in areas of functioning. For example, highly capable in elective surgery or education but highly stressed in after-hours and emergency scenarios.

All anaesthesia providers should monitor themselves and their colleagues for signs and symptoms of functional impairment so that impairments can be detected early and support and professional help can be offered.

Recommendations

Be aware of the general and specific health issues that may impact your own professional life.
Be aware of your own issues with health and wellbeing. Know yourself.
Seek timely and appropriate help if concerned about your own physical, mental, emotional, or special sensory health.
Take time to look after your own health and wellbeing:
- take time off work for recreation and recuperation
- ensure adequate and appropriate nutrition
- maintain physical fitness
- ensure adequate sleep
- maintain social connections
- practice mindfulness, meditation, and other forms of relaxation
- develop and enjoy other interests and hobbies
- look after your emotional wellbeing
- have timely and regular physical check-ups and ensure medication compliance
Be particularly aware of fatigue. Avoid commitment to a quantity of clinical work that may result in excessive fatigue. If fatigue is leading to unsafe practice, this should be addressed with the department and institution, and clinical work should be reduced.
Limit or modify your own practice if patients and/or coworkers are being placed at undue risk, until personal physical, mental, and emotional health issues are resolved or adequately managed.
Maintain adequate investments, disability insurance or contingency plans to ensure your ability to attend to personal health and wellbeing issues without major financial penalty or disarray.
Seek help if feeling hopeless, needing drugs or alcohol, or if life is spiralling out of control.

The following Helplines are available:

SASA Wellness in Anaesthesia Support Group: dreamdocsa@gmail.com
If you want to speak to anaesthesia colleagues that know what you are going through.

Healthcare Workers Care Network (0800 212 121)
If you wish to talk to registered psychology professionals.

Discovery Healthy Doctors (0800 323 323)
For self-assessment and self-reading. This resource has financial, legal, physical health and mental health support.

Institutional responsibilities

“Institution” in this instance refers to the hospital, faculty and/ or departmental administration that has authority over the provision of anaesthesia and the practice of anaesthesia providers. It is recognised that the HPCSA has authority over the anaesthesia physician provider and has a stake in regulating, promoting and supporting physician wellness.

Anaesthesia and/or faculty leadership must support physician health and wellness through administrative structures that promote and support a healthy workplace.

Creating and sustaining a culture of psychological safety is essential. Psychological safety is the shared belief held by members of a team or department that the team is safe for interpersonal risk-taking. These risks include the ability to show and be oneself without fear of negative consequences to self-image, status or career advancement. It also includes speaking up when a problem or mistake arises, without fear of being blamed, punished or humiliated, voicing opinions without fear of being judged, and reporting issues without fear of negative repercussions. When team members feel psychologically safe at work, it is easier for them to engage fully, participate in meetings, solve problems, report issues, collaborate on projects and support each other. It helps create a much more trusting and respectful organisational climate, which leads to higher psychological safety, a self-fulfilling cycle. More information can be found on the SASA website.

Peer support mechanisms are helpful to identify those at risk or in difficulty, activate support systems and encourage maintenance of compliance and safety. It alleviates isolation and alienation and creates a team-based culture of collaboration and support. More information can be found on the SASA website.

Recommendations

Daily work hours

Regulation of work hours and shift patterns taking into consideration the dangers of chronic and excessive fatigue. The specific number of prescribed working hours is covered in Hours of work.
Structuring of operating room schedules to permit necessary breaks for everyone for personal physiological needs and nutrition.
Implementation of staffing flexibility to allow for taking unexpected leave for personal health or family responsibility reasons, for exhausted physicians after a difficult list or call and for unforeseen events such as after critical incidents.
Encourage departments and facilities to create anaesthesia care teams to improve both patient safety and healthcare provider health.
Always encourage the availability of appropriately skilled help (at the very least, a phone call away), especially in out-of-operating room OR locations and after-hours for emergency cases.

On-call commitments

Transparent and equitable scheduling policies should be followed.
Schedule adequate rest and recuperation post-call, and if possible, provide support to get home safely if unfit to drive a vehicle post-call due to fatigue and exhaustion.
Discourage scheduling of non-urgent procedure during after-hours to minimise the demand for OR resources during periods of minimal staff coverage.

Ensure transparent and equitable policies

Vacation and leave
Exam and study leave
Scheduling of shifts and calls
Appointments and promotions

Build psychologically safe departments and have appropriate mechanisms to report and deal with issues such as

Workplace harassment and/or bullying
Discrimination based on gender, race, culture, sexuality, religion, or disability
Enforce a clear zero-tolerance policy

Create a formal response and support system to address fall-out in personnel after stressful events (e.g., critical adverse events, unexpected deaths, disasters such as terrorism and fire, patient complaints and violence, etc.)

Appropriate critical incident debriefing training for appropriate senior consultants
Access to trained critical incident support personnel
Peer support mechanisms
Formal policies on the timing and follow-up of critical incident management to ensure follow-through
Please see critical incident debriefing section on https://www.sasaweb.com.

Substance abuse and other functional impairment rehabilitation

Formal and transparent structure and policy on supervision and rehabilitation of impaired physicians
Encourage compassion and support
Zero tolerance for judgment, bullying, and humiliation

Dignified retirement pathway

Formal structure and policy on retirement pathway based on transparent functional impairment assessments and reporting
Access to lower acuity and complex cases where appropriate and available
On-call duty reduction strategies

Responsibilities toward healthcare workers, trainees and colleagues

Health and wellness

Every anaesthesia provider has a role in helping colleagues with significant health or wellness problems, especially as it impacts the safe, ethical and caring delivery of medical services to patients.

Be aware of warning signs of significant illness, addiction, excessive stress, or burnout.
Approach colleagues with serious concerns about health or wellness and encourage them to seek help or advice from an appropriate source. Please see the support section on the SASA website.
Encourage colleagues whose ability to practice medicine becomes temporarily or permanently impaired to appropriately modify or discontinue practice.
Be supportive and compassionate towards those who have sought help with a health or wellness problem and are recovering or undergoing treatment or rehabilitation for that problem.
Respect the confidentiality of those who have health or wellness issues.
Realise that it is a legal obligation to report such concerns to the HPCSA if there is reason to believe a fellow clinician is in danger.

Trainees

The period of training is fraught with challenges: long working hours, stressful working conditions, difficult shifts, relationship challenges, new parental responsibilities, exams stress coupled with inadequate time for studying. Compassion and support are not only helpful but essential in promoting health and wellness among the trainees.

Avoid bullying, shaming, and blaming behaviour. Trainees are still learning, and mistakes are unavoidable. Mistakes are opportunities for learning and adjustment rather than punishment and shaming. Encourage openness and honesty and empower conversations and discussion to achieve learning.
Create supportive and flexible work environments for those facing stressful challenges: exams and intense study periods, new parenthood (e.g., baby and breastfeeding challenges) and family responsibilities, added work responsibilities (new consultants), etc. Have transparent structures and policies to allow leave and flexibility for these periods.
Have an open-door policy and ensure a psychologically safe culture to allow feedback and suggestions within the department. Every group of trainees is different, and their needs differ. Be prepared for adaptation and flexibility.

Legal responsibilities

The HPCSA Guidelines on Ethical Rules stipulate the following:

Reporting of impairment or unprofessional, illegal or unethical conduct.

A student, intern, or practitioner shall –

report impairment in another student, intern, or practitioner to the board if they are convinced that such student, intern, or practitioner is impaired,
report their own impairment or suspected impairment to the board concerned if they are aware of their own impairment or have been publicly informed, or have been seriously advised by a colleague to act appropriately to obtain help in view of an alleged or established impairment, and
report any unprofessional, illegal, or unethical conduct on the part of another student, intern, or practitioner.

This is a legal requirement.

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South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_Reviewed by: C Lee