Psychosocial workplace safety in mental health services – Commentary and considerations to improve safety

Abstract

Objectives

Psychosocially unsafe workplaces are related to burnout, especially amongst trainees and psychiatrists. Burgeoning research on psychosocial workplace safety indicates the importance of organisational governance to reduce adverse professional, and consequently patient, outcomes in healthcare by balancing job demands and resources. We provide a brief commentary on the relevance of the concept of the Psychosocial Safety Climate model for mental health services and healthcare workers, and considerations for action.

Conclusions

Based on the Extended Job Demand-Resource model, the Psychosocial Safety Climate model has been developed and validated in community and healthcare environments. Psychosocial safety is also an Australian workplace safety requirement. An important direction to improve working conditions, reduce adverse outcomes, and improve recruitment and retention of healthcare workers, may be to adopt and formalise psychosocial workplace safety as a key performance indicator of equal importance to productivity for mental healthcare services.

Concerns about psychosocial safety in health services have been highlighted by a recent report from the Auditor-General’s Office of Victoria into three health services. ¹ In all three services mental health and wellbeing had deteriorated since 2019 with no effective supervision of psychosocial wellbeing and no processes to manage psychosocial hazards. ¹ This is of concern as poor psychosocial safety can lead to negative outcomes for healthcare workers, and consequently patients, as well as deleterious effects on the productivity and effectiveness of healthcare.^2,3

A 2024 RANZCP survey of 1269 of 7200 psychiatrists and trainees found that over three quarters reported symptoms of burnout, which 82% attributed to workforce shortages. ⁴ Furthermore, 13% of trainees, 14% of early career psychiatrists, and 33% of all psychiatrists, had considered leaving the profession in the next 3 years. ⁴ Mental healthcare is emotionally demanding, as evinced by the high levels of burnout and moral injury cited in the survey. ⁵ There is burgeoning evidence that mental healthcare workplaces present psychosocial safety risks, consistent with local and international research showing burnout is prevalent in psychiatry.^6,7 To encourage discussion, we propose using the framework of the PSC to consider possible strategies to improve working conditions, mental health and wellbeing in mental healthcare.

Considering psychosocial safety in the workplace

The Psychosocial Safety Climate model focuses on the balance between productivity and psychological health based on the Job Demand-Resource model, that is, when job demands exceed worker resources, worker stress results, and leads to health erosion. ²

The PSC is defined by the policies and procedures instituted by organisational managers that ensure protection of workers’ psychological health and safety. ² The focus is on systemic work stress factors and comprises:

(1) The degree of senior managerial awareness, commitment and support on minimising, or if possible, preventing stress;

(2) The relative priority accorded to psychological health and safety compared with productivity goals;

(3) The clarity and effectiveness of organisational communication for psychological health and safety; and

(4) The extent of manager and worker participation in appropriate measures for psychological health and safety. ²

A high-quality PSC represents organisational effectiveness on all of the preceding. Thus, the PSC mediates an adequately resourced motivational pathway for workers through engagement and positive outcomes.^8,9

In contrast, a lower-quality PSC may lead to negative outcomes from job demands exceeding resources, and cause worker health erosion (psychological distress, depression, anxiety etc.) ⁹ as well as lower workplace productivity (absences and presenteeism). ¹⁰

The potential role of PSC for workplace safety is discussed in the following.

Consequences of a poor psychosocial safety climate on healthcare workers

The Australian Workplace Barometer study of the general working population (n = 4242) from 2014 to 2015 found that poor PSC was associated with higher sickness-related absences and presenteeism (when workers are at work, but are less productively engaged due to health problems). In turn, both absences and presenteeism were associated with higher psychological distress, and depression. ¹⁰ Lower-quality PSC is also associated with post-traumatic stress disorders through workplace bullying and harassment. ¹¹ In contrast, higher levels of organisational engagement were associated with lower sickness-related absences and presenteeism. ¹⁰

A recent systematic review of medical practitioners’ working conditions as viewed through the Job Demand-Resource model, found that job resources (e.g. support levels) predicted work engagement, while onerous job demands were associated with emotional exhaustion. ¹² In turn, better quality of clinical care was associated with more job resources, and lower levels of emotional exhaustion and job demands. ¹² Another systematic review of the Job Demand-Resource model found that higher job demands were related to compassion fatigue in mental health professionals, while supervisor, peer and organisational support resources were protective. ¹³

A study of 606 workers during the COVID-19 pandemic found, when there were excessive healthcare work demands, a higher quality PSC protected against counterproductive ‘workaholism’, while increasing worker engagement. ¹⁴ Similarly, in a recent study of 277 healthcare workers, autonomy and social support were found to diminish the relationship between PSC and worker stress, and lower-quality PSC was associated with increased stress. ¹⁵

In healthcare workplaces, there are also physical safety risks from procedures, equipment and patient interactions. A recent study of 463 hospital workers found that the physical safety climate was intertwined with PSC, with PSC predicting outcomes for staff accidents, absences and patient quality of care incidents. ¹⁶

Perhaps PSC reflects a broader managerial and organisational awareness of, and commitment to, worker safety in general. This can be improved by quality job design, prioritising worker wellbeing, and enacting robust organisational policies, practices, and procedures that enable frank and effective worker-to-management communication. ¹⁷

As concluded in a recent scoping review, the translation of the knowledge on PSC into psychosocial safety behaviours (such as work system planning, promotion of psychosocial support-seeking and reporting of psychosocial hazards) remains challenging, and there has been little research to date, and a lack of focus on psychosocial safety, including on managerial behaviours that may promote PSC. ¹⁸

There were estimated direct and indirect economic costs for low-quality PSC of AUD$6 billion in 2016, ¹⁰ a figure likely to be higher now, in the context of the COVID-19 pandemic and workforce challenges. ¹⁹ Increased job demands (increased workload and working hours) and reduced resources (workers, infrastructure) during the COVID-19 pandemic have most likely negatively impacted on PSC, and this has contributed to an international healthcare worker shortage, including of psychiatrists and trainees.^4,5,19 Therefore, there are likely to be considerable human and economic costs resulting from poor psychosocial safety in the workplace, including in mental healthcare.

There is emergent research on the potential benefits of improved PSC during the COVID-19 pandemic. A recent Australian study found that PSC as perceived by healthcare workers, together with employee personal psychological resources, termed Psychological Capital, ²⁰ and measures of wellbeing, were associated with more than half of their self-reported innovative behaviours. ²¹ The authors of this study also noted that the variance of PSC explained almost two-thirds of employees’ self-reported wellbeing, and suggested that there were expectations of healthcare staff to be innovative in conditions of austerity-driven demand, high work intensity, harassment, and increasing health and safety risks. ²¹ Such poor PSC is counterproductive to wellbeing and innovation, and the future healthcare workforce supply.

Translating psychosocial safety climate to the workplace

As the recent Australian Workplace Barometer study concluded, there are policy implications arising from the PSC research, ¹⁰ including for healthcare workplaces.

Safe Work Australia, which promulgates workplace safety standards for the Australian workforce, has legislated definitions for psychosocial hazards in the workplace, ²² which are enforced in State and Territory jurisdictions under model Workplace Health and Safety (WHS) laws, with the exception of Victoria. ²³ This legislation requires that a person conducting a business undertaking (PCBU) ‘…must eliminate psychosocial risks, or if that is not reasonably practicable, minimise them so far as is reasonably practicable. The model WHS Regulations require PCBUs to have regard to all relevant matters when determining what control measures to implement’. ²²

For the purposes of our discussion, a person conducting a business undertaking therefore includes those managing the delivery of healthcare services and healthcare workers. The legislated psychosocial workplace safety requirement could be addressed by a range of measures at different policy levels. Safety should be addressed by workplace systemic control measures, rather than less effective individual interventions. ¹⁰

Local workplace-level controls may include leadership/managerial commitment to a workplace conducive to mental health (to which we would add that this should be a key performance indicator of managerial performance), ²⁴ as well as specific policies and procedures for bullying, intimidation and harassment, aggression, managing work-related fatigue, and worker consultation processes. ¹⁰

Organisational-level controls may include the following: designing safe work systems; workforce planning for safe job demand, time pressure and resource levels (recalling PSC is based on the Job Demand-Resource model); all with regard to individual workers’ role, capacity, autonomy, validation, reward and recognition, as well as flexible work arrangements. ¹⁰ Individual and team-based crafting of work to enhance PSC has demonstrated benefits for employee motivational engagement and organisational commitment. ²⁵

An essential area of future research, evaluation and implementation is for the promotion of Psychosocial Safety Behaviours which apply across local workplace (e.g. job design, rostering), organisational (e.g. psychosocial hazard reporting) and individual worker (help-seeking) levels. ¹⁸

Translating psychosocial safety to mental healthcare service workplaces

Burnout, a multidimensional psychological injury that is linked to perceptions of psychosocial safety, has been reported as prevalent in psychiatrists and trainees as described in the introduction.^4,5,26 There is much in common in the recommendations for addressing burnout and those above for improving psychosocial safety, such as the following:

(1) Duty-hour limitations including the ‘right to disconnect’,

(2) Safer work conditions,

(3) Active engagement of doctors in psychosocial safety programs, and

(4) A validating and supportive work environment that enhances autonomy and sense of control. ²⁶

However, the evidence-base on PSC is less specific to mental healthcare services, with the exception of the linkage of compassion fatigue with workplace trauma, workload and work environment, and the psychiatrist and trainee data cited above.^4,5,13,26 A holistic approach will also need to address other job stressors such as bullying, intimidation and harassment, ²⁶ lack of interesting and stimulating work duties, ²⁶ excessive work demands ⁵ and inadequate resources and/or infrastructure. ⁵ Until evidence is forthcoming, general workplace and organisational-level measures need to be implemented, and evaluated for their effectiveness in improving PSC.

Mental healthcare managers, and leaders, including psychiatrists, and other mental health professionals, are collectively accountable for a mentally healthy workplace. This requires expert leadership from healthcare professionals, such as psychiatrists, with specific expertise in work roles, ²⁷ to more effectively calibrate and coordinate job resources and demands.

Potential considerations to address psychosocial safety in mental healthcare

To promote further reflection and discussion we propose the following:

(1) The wellbeing of staff should be a key performance indicator for mental healthcare service managers. ²⁴

(2) Mental healthcare services must invest in workforce planning and continuing professional development to manage work demands.^5,28

(3) Expertise-based leadership by managers conduces to greater employee satisfaction due to provision of specific advice and supervision, and this has been demonstrated in medical administration. ²⁹

(4) A collaborative design of jobs that includes the input of frontline workers to be sufficiently resourced for efficiency, ¹⁰ and be better designed for health and wellbeing, including psychosocial safety. This can also involve Industrial and worker representatives providing specific input into Enterprise Agreements in order that psychosocial safety and wellbeing are effectively supported and enforced by employer and employee.

(5) In day-to-day work, an effective risk and safety management system is necessary, over and above simple safety or risk reporting. ¹⁸ This requires that Occupational Health and Safety Officers are employed according to their statutory responsibilities under the relevant Workplace Health and Safety laws for the jurisdiction, and these officers are independent and accessible for workers to report, particularly, psychosocial safety concerns.

(6) At the individual employee level, and within work units, there needs to be both an awareness and accessibility of the safety and risk reporting mechanisms, ¹⁸ as well as access to Employee Assistance Programs, and leave to seek medical and psychological care through the worker’s GP, and allied health professionals, if required. ¹⁸

Conclusions

Workplace psychosocial safety measures are particularly relevant to mental healthcare services given the emotional and structural demand-resource challenges of the work, due to heightened risks of resultant burnout and psychological distress.^4,26 High-quality PSC is necessary for all organisations, large and small, and the Australian framework of Workplace Health and Safety laws for psychosocial safety applies across private, public and NGO sectors – including mental healthcare services. Policies and procedures to enhance the quality of PSC may provide a structured framework for improvements, while field-specific evidence-based interventions are investigated. This could be enabled by including maintenance of high-quality PSC as a key performance indicator for healthcare organisations.