The strain on health workers made headline news through the pandemic. But pressures on the health workforce predated COVID-19, and are still contributing to plummeting wellbeing and job satisfaction — just as Canada faces a dire shortage of health professionals.
According to the most recent National Physicians Health Survey (NPHS), a poll of more than 4,000 doctors and medical learners across the country, eight in 10 respondents had experienced bullying or harassment on the job — four in 10 “frequently” or “often.” Over half (53%) reported burnout. Forty-eight percent screened positive for depression. Perhaps not surprisingly, 51% of practising physicians said they were likely to reduce or modify working hours. Which, of course, puts further pressure on the health workforce.
Until the systemic, cultural and workplace occupational hazards negatively impacting health providers are openly addressed, it’s a cycle likely to continue. A coordinated, comprehensive response — including physical, psychological and cultural safety — is urgently needed.
Physical safety for health workers
Provincial legislation ensures that health care institutions take all possible measures to minimize workplace hazards.
At a federal level, the CMA was instrumental in the passage of Bill C-3, making abuse or harassment of health workers — which significantly increased during the pandemic, both at work and online — a criminal offence.
But physical safety involves more than protection from injury. It also means supporting physicians and learners managing health limitations or disabilities.
Dr. Franco Rizzuti, Medical Officer of Health for Alberta Health Services, is the president of the Canadian Association of Physicians with Disabilities. He calls many work environments “ableist,” with few accommodations for health professionals who need them.
He points to a new building at St. Paul’s Hospital in Vancouver. In the original design, it included only one accessible call room, where residents can sleep. No one considered there might one day be two residents or physicians using wheelchairs.
Medical schools also struggle with accessibility, Dr. Rizzuti says. While admissions have advanced to reflect diversity, many schools have aging infrastructure. They often lack even accessible or inclusive washrooms.
“Imagine being admitted to a school, only to find you can’t easily access a washroom between classes. This rapidly creates trauma for the learner. You would expect those in the medical field to be more aware and supportive.” — Dr. Franco Rizzuti
Psychological safety for health workers
The Mental Health Commission of Canada led the development of a national standard for psychological health and safety at work a decade ago.
Sapna Mahajan, who was part of that work, says it shifted the focus from simply including mental health services in employee benefits to actively promoting and protecting wellness in the workplace. One missing piece, however, is a parallel shift in medical culture.
Asked about possible barriers to accessing wellness support services, 55% of respondents to the CMA’s NPHS said “believing the situation is not severe enough,” 47% “being ashamed to seek help” and 21% cited fears about career advancement, or even the ability to practice. Only 26% had seen a psychiatrist, psychologist or licensed counsellor in the past five years.
As Dr. Rizzuti notes, physicians are traditionally expected to be “invincible, unfailing in their service to patients.” Asking for help is seen as a weakness ¾ whether a doctor or medical learner is managing a physical disability or mental health concerns.
But where stigma or fear of negative reprisals for speaking up or seeking help exist, there is no psychological safety. Says Mahajan, that makes normalizing mental health care for providers as critical as expanding support services. One model is Michael Garron Hospital in Toronto, where leaders are openly sharing their own use of Employee Assistance Programs.
Cultural safety for health workers
Perhaps most difficult to talk about openly is cultural safety at work — which includes racism and discrimination in health care, as well a lack of respect for different traditions and practices.
In learning and clinical environments, health workers continue to face both implicit and explicit transphobia, homophobia, anti-Black and anti-Indigenous racism, to name only some targets of prejudice.
Dr. Cornelia (Nel) Wieman was the first Indigenous woman in Canada to qualify as a psychiatrist. In medical school, she says, the presumption was that she’d been admitted “because you’re an Indian.” In a previous interview with the CMA, she recalls “sitting at a table and having my peers speak out against admitting more Indigenous medical students.” Their fear: “that it would bring down the academic standards.”
Thirty years later, a study of 375 Alberta doctors indicated that 67% had an implicit preference for white over Indigenous people, and 25% an explicit preference.
One of the Truth and Reconciliation Commission’s 94 calls to action was to address prejudice through mandatory training. In response, medical schools across Canada committed to Indigenous health curricula. At the Northern Ontario University of Medicine, students spend four weeks in an Indigenous community. The CanMEDS Physician Competency Framework is also undergoing revision to include anti-racism, anti-oppression, EDI and accessibility goals.
Health institutions have adopted cultural safety goals as well. And Dr. Wieman, who is now the Medical Officer of Health for BC’s First Nations Health Authority (FNHA), was instrumental in the development of a Cultural Safety and Humility Standard for the province to help leaders “identify, measure and achieve” progress.
Getting there will require not only removing barriers to practice or mistreatment at work but demonstrating that racism will not be tolerated and different perspectives and expertise will be welcomed.
Integrating physical, psychological and cultural safety
A holistic approach to health worker safety — understanding and addressing the interplay between physical, psychological and cultural safety — is also essential to wellness in work environments across the continuum of care.
“Cultural safety to me, as an Indigenous person and physician, actually encompasses physical and psychological safety.” — Dr. Nel Wieman
Dr. Rizzuti agrees. It took time for occupational safety to extend to mental health, he says. Broader integration of physical, psychological and cultural safety is the logical next step.
“I actually think it behooves us, in terms of making meaningful change, to recognize they are fully interconnected — like a lot of things in health,” he says.
One comprehensive approach to physician safety is the University of Alberta’s three-year action plan, A Culture of Care. It recognizes that “a culture of care must address all aspects of safety — physical, psychological and cultural,” and that all three must become part of an organization’s core values, with an end state where everyone owns their “safety performance.”
A thriving health workforce depends on more efforts like these — across the country. Narrow definitions of workplace safety put Canada’s health professionals, and patients, at risk. Where health providers lack protection from abuse, where they do not feel welcomed and respected, where they lack support as people as well as professionals, they are fundamentally unsafe.
Dr. Wieman, Dr. Rizzuti, Sapna Mahajan and Philip Stack, the co-chair of the University of Alberta’s action plan for A Culture of Care, will be speaking at the CMA’s 2023 Health Summit on Aug. 17.
Working definitions of physical, psychological and cultural safety
The CMA has drafted working definitions of physical, psychological and cultural safety over more than 12 months of engagement, learning and discovery work — and we expect these definitions to continue evolving:
Physical safety is the result of an environment free of harm or injury, threats of harm or injury, or near harm or injury which may be inflicted by a person, substance, object, hazard, or occupational practice.
Psychological safety is a climate of trust and respect in which people are comfortable working to their full scope of practice, and hold the belief that teammates and leadership will not embarrass or punish a colleague for speaking up in the line of work.
Cultural safety is an outcome based on respectful engagement that recognizes cultural preferences (e.g., customs, rituals) and strives to address inherent power imbalances in the health care system. It results in an environment free of racism and discrimination, where people feel safe to express themselves.