Practical psychiatry: Providing temporary psychiatric cover

Abstract

Objective

Psychiatric cover for healthcare staffing shortfalls is increasingly common post-pandemic. We aim to provide comprehensive practical advice on providing temporary inpatient or outpatient cover as a psychiatrist, based on the authors’ clinical experience and the existing research literature.

Conclusions

There is limited peer-reviewed advice available on providing safe and effective temporary psychiatric consultant cover for patient care. We suggest a framework for reviewing the potential hazards and benefits of a temporary post, and planning for the role, guided by consideration of the following: caring for patients, supporting staff, working with peers, and understanding local healthcare systems and the local regulatory environment. Application of this reflective framework is informed by the psychiatrist’s assessment of the temporary role, and consideration of the local service conditions.

Consistent leadership by psychiatrists contributes to the stability of the health services and quality of care. However, this ideal situation was disrupted by the COVID-19 pandemic, and increasingly, there are times when psychiatrists provide urgent cover for the work of their peers. We discuss considerations in leading temporary cover for psychiatrist peers within the same psychiatric service, in addition to, or instead of, a psychiatrist’s substantive role. The purpose of such cover is for leave and unexpected healthcare staffing shortfalls, which are unfortunately increasingly common post-pandemic. ¹

Surprisingly, a non-systematic search across multiple databases (Medline, PsycINFO, Google Scholar, and Scopus) found very little peer-reviewed advice on consultant leadership when covering leave/shortfalls, or, indeed, when working as locums. There has been previous cogent advice about working as an external (to the service) locum psychiatrist. ² Furthermore, social anthropological research provides general insights that indicate that humans’ model and learn from those they perceive as displaying expertise in the specific skill domain they are developing. ³ In this case, the expertise inheres to clinical psychiatrists, on which some of our advice draws. Burgeoning leadership research also shows medical practitioners are less likely to resign and more satisfied with their work based on their medical supervisor’s effectiveness. ⁴ It can be challenging to provide this expert leadership on a temporary basis. While psychiatrist mentors and colleagues may provide some of the following advice ad hoc, our aim is to systematically draw together the various skeins of experiential advice, together with such literature as exists. In this context, we provide a brief framework for psychiatrists to consider requests to provide temporary cover.

Do you want to provide cover?

The benefits may include opportunities to work with and learn from a broader range of patients and clinicians, similar to the experience of being an external locum. ² This can also promote better empathy and support for colleagues. There may be interprofessional learning from working with different psychiatric teams.

Unfortunately, many psychiatric services that require frequent temporary cover may have difficulty recruiting and retaining staff for several reasons that may include: remoteness, chronic under-resourcing, low morale, lack of patient and staff wellbeing and safety, lack of chain of command/management, poor communication, and sometimes bullying and harassment. ⁵

The most difficult situation is to be asked to carry another’s workload and team, whilst retaining responsibility for one’s substantive duties. It is easier when one psychiatrist’s duties are switched to cover for another, but of course, this has flow-on effects for other colleagues, who may need to cover for the one covering and so on. Considerations for whether to provide temporary cover:

• Who is asking you to cover and can/should you refuse?

• Are there organisational, infrastructural, or staffing reasons why this position doesn’t have cover already?

• Identify the medico-legal, clinical, and other workplace risks, as burned-out co-workers may not be able to provide sufficient support and information.

• Will this mean you will be doing two jobs? Is this feasible? Is it safe?

• Will there be benefits for you in the experience?

• Talk to the person you are replacing, if possible, especially for a handover.

• Discuss your decision with your peer group, industrial advocate (union), and medicolegal indemnity provider as needed.

• Who else do you need to meet with to gain collateral information about the role?

• Is there an email and documentation trail about the temporary role and your responsibilities?

Preparing to act in the role

The duration of cover, and the nature of the role, help in understanding the scope of responsibility, and feasibility of influence. For example, if a psychiatrist is required to provide emergency cover for a few days, it may be reasonable to focus on triage of crucial tasks, supported by advice from clinical staff and peers. Alternatively, if a psychiatrist is covering longer-term, say for one month, there may be more opportunities to shape the role based on discussions with managers and clinical staff.

Points to consider:

• Define the boundaries of the role with management.

• What is the purpose? Keeping the lights on for a short period, or longer service development?

• Know your line management and where to take report workplace issues, health, safety, and wellbeing concerns.

• Know your junior staff (if any) and utilise their systems expertise.

• Ascertain the basic infrastructure of digital health records, the medico-legal regulatory environment for mental health legislation, and statutory responsibilities such as child or elder abuse notification. ²

Developing a (temporary) workflow

Practically, it will be difficult to gain a quick overview of the psychiatric service and its functioning, so, as a covering psychiatrist this will be an iterative knowledge and skills exercise through observation and seeking advice and support from junior medical staff, peers, managers, and allied health clinicians. Points to consider:

• Can you integrate the extra work of covering (regular meetings etc.) into your existing duties?

• Familiarise yourself with existing treatment plans from your predecessor and be comfortable ahead of time about how much you are willing to change them.

• There may be tensions regarding leadership of clinical care (e.g., an allied health staff member who disagrees with the substantive psychiatrist’s management of a patient may approach the covering psychiatrist to alter the care plan).

• However, given that local staff know the patients and the environment, the covering psychiatrist often has to cautiously trust the skills and actions of the team. ²

• Assess staff dynamics within the service you are covering and alter your approach accordingly.

• Patients and their families are often distressed by the need to discuss care-planning with different covering psychiatrists.

• Maintain contact with longstanding peer review group can help the covering psychiatrist navigate challenges.

Future directions

In the face of ongoing healthcare worker shortfalls, there will remain a demand for both covering psychiatrists, locum psychiatrists (as already seen in the United States prior to the pandemic), ⁶ and perhaps innovative models for patient care and multidisciplinary team support via videoconferencing and telepsychiatry. ⁶

The role of telepsychiatry and videoconferencing became prominent in private psychiatry during the COVID-19 pandemic, with the Australian government providing reimbursement for patients and/or psychiatrists to access telehealth either as an inpatient (in time-limited circumstances) or outpatient. ⁷ Perhaps, there are opportunities for the provision of local psychiatric cover via telehealth in busy understaffed metropolitan services, and in specific circumstances when travel for face-to-face interaction is impracticable, such as during a pandemic lockdown, fires, and floods, as has recently happened in Australia.

Conclusions

There are benefits and challenges from working as a covering psychiatrist, which can be navigated by reference to a map of the psychiatric service structure and function, and guided by clinical staff, peers, and managers. We have distilled a brief experientially based framework of points of consideration and questions to assist psychiatrists in the decision as to whether and how to provide effective cover for colleagues and health service teams.