https://orcid.org/0000-0002-5460-6169
Abstract
Protection of the public is the paramount aim for health practitioner regulation, yet there has been growing concern globally on the association between regulatory complaints processes and practitioner mental health and wellbeing. The objective was to understand the experience, particularly distress, of health practitioners involved in a regulatory complaints process to identify potential strategies to minimise future risk of distress. Semi-structured qualitative interviews were conducted with health practitioners in Australia who had recently been through a regulatory complaints process, together with a retrospective analysis of documentation relating to all identified cases of self-harm or suicide of health practitioners who were involved in such a process over 4 years. Data from interviews and the serious incident analysis found there were elements of the regulatory complaints process contributing to practitioner distress. These included poor communication, extended time to close the investigation, and the management of health-related concerns. The study found external personal circumstances and pre-existing conditions could put the practitioner at greater risk of distress. There were found to be key moments in the process—triggers—where the practitioner was at particular risk of severe distress. Strong support networks, both personal and professional, were found to be protective against distress. Through process improvements and, where appropriate, additional support for practitioners, we hope to further minimise the risk of practitioner distress and harm when involved in a regulatory complaints process. The findings also point to the need for improved partnerships between regulators and key stakeholders, such as legal defence organisations, indemnity providers, employers, and those with lived experience of complaints processes. Together they can improve the support for practitioners facing a complaint and address the stigma, shame, and fear associated with regulatory complaints processes. This project provides further evidence that a more compassionate approach to regulation has the potential to be better for all parties and, ultimately, the wider healthcare system.
Introduction
There has been growing concern globally about the association between regulatory complaint processes and the mental health and wellbeing of the practitioner who is subject to a complaint [1–6]. Previous research suggests that health practitioners involved in such a process can experience heightened levels of distress, anxiety, and shame, which impacts their personal lives and their families, as well as their professional identity and practice [2, 3]. There have also been tragic cases of practitioners involved in complaints processes who have died by suicide [1].
Worldwide, there is consensus that patient safety must be the paramount aim for healthcare systems and regulators. Those regulating the workforce are responsible for ensuring that practitioners are suitably trained, qualified, and safe to practise. Regulators consider complaints and concerns raised by patients, families, and others, about the performance, conduct or health of practitioners. For example, complaints about performance might relate to whether a practitioner obtained appropriate patient consent for a procedure, missed a diagnosis or made a serious prescribing error. Complaints about conduct include inappropriate relationships with a patient, fraud, dishonesty or any criminal conduct outside of their practice. With health, a concern might be raised if the practitioner has an unmanaged health condition which impacts on their ability to provide safe care. These complaints may result in regulatory action for the health practitioner, such as suspension, restrictions on their practice or, in rare circumstances, loss of the right to practise. This process emphasises patient safety and an independent investigation to address risk to patients when professional standards are not met.
In Australia, registered health practitioners across 16 professions are regulated by 15 National Boards (the Boards) and the Australian Health Practitioner Regulation Agency (Ahpra) as part of a national, multi-professional regulatory scheme. In 2021/22, Ahpra closed over 10 000 complaints about health practitioners; regulatory action was taken on just under 14% of these [7]. When Ahpra receives a complaint about a practitioner, they are required by law to assess it. Because Ahpra and the Boards are a regulator and not a complaints resolution body, the focus is on determining if the practitioner poses a risk to future patients. Once assessed, if there is determined to be no or low risk, the complaint may be closed quickly; many are closed within 90 days. Where a complaint is complex or highlights potential risks with the practitioner’s performance, health or conduct, the regulatory process may take much longer, possibly up to several years when other organisations are involved, such as the police or courts. The Boards have a range of actions they can take to address any ongoing risk to the public, including placing restrictions on the practitioner’s ability to practise. In very serious matters, the Boards can refer the complaint to a court or tribunal which has the power to cancel a practitioner’s registration.
Past work has highlighted the stress and distress of those involved in a complaint [8]. In response, Ahpra has made changes to create a more humane regulatory environment for both practitioners and complainants. These include increased telephone contact, minimising legalistic language, and greater use of risk assessments to stratify complaints early [8, 9]. Improvements to complainant experience have been central to this work.
This study focused on the first-hand experience of practitioners who had been through a complaints process. It also sought to better understand the circumstances in which practitioners facing a complaint had attempted or died by suicide, to know whether there are things that can be done, either alone or in partnership with others, to prevent this catastrophic outcome.
The aim of this study was to answer the question: what factors are associated with the distress of practitioners when involved in a regulatory complaints process?
Methods
This was a mixed methods study incorporating semi-structured interviews and document analysis that received ethical approval from the Metro North Human Ethics Committee, Metro North Hospital and Health Service, Brisbane, Australia (ID: 82390 and ID: 84222). All of the data pertaining to the work was stored on password protected files (see Fig. 1). The research team was made up of current Ahpra staff (S.B., P.M., S.A., E.S., J.E., and L.B.) and external experts in the field (A.V.D.G.) who contributed to the work. S.B., A.V.D.G., S.A., E.S., J.E., and L.B. are female and P.M. is male. No team members had established relationships with participants prior to study commencement, or prior knowledge of the complaint the participant was involved in.
Mixed methods study design.
Practitioners were contacted by email by a member of the research team. Semi-structured interviews with a purposive convenience sample of practitioners were conducted by Zoom (by S.B. and P.M.) to hear first-hand experiences of the regulatory process, to understand if, and when, it caused distress. S.B. and P.M. are both experienced interviewers and have prior experience with quality improvement in heath regulation. Interviewers confirmed with participants that they had no involvement with the notifications process or knowledge of the participant’s matter prior to commencing the interview, but were seeking to find ways to improve the notifications process and learn from those who had experience of it. Interviews were recorded, transcribed, and anonymised for analysis; written information and consent forms were provided to participants by email and consent was obtained prior to recording the interviews. Practitioners were asked about their experience, any associated distress, communication with Ahpra, support networks, any other helpful actions, and suggestions for improvement. All participants were offered follow-up support at the end of the interviews and care was taken to acknowledge the potential for distress arising from the interview itself.
Under supervision of ES and SA, two research team members with qualitative research experience (JE and LB) coded and analysed the interview data. Researchers completed a template analysis, a codebook approach to thematic analysis, following Brooks et al. [10] and King in Symon and Cassell [11], as described in Fig. 2. Both interviewers and coders kept notes throughout data collection and met regularly to discuss the development of the template.
Template analysis detail.
Additionally, researchers undertook document analysis. All cases where a serious incident report (SIR) had been created in Ahpra’s internal database relating to an incident of self-harm, attempted suicide, or death by suicide of a health practitioner who was currently (or recently, up to 12 months prior) involved in a regulatory process were reviewed. These SIRs are systematically collected by Ahpra when the organisation is informed of a relevant serious incident (SI) involving a practitioner. Once this initial list of SIs was collated, researchers used a variety of sources to classify each case as either self-harm, attempted suicide, suspected suicide or confirmed suicide. To do this, researchers relied on as much information as possible matched to the specific case. This included all Ahpra correspondence with the practitioner and any associated parties, including coroners’ reports, documentation from a practitioner’s legal representative, family, treating practitioner or employer, and media reports. The classification of ‘suspected’ suicide was used where additional sources were unavailable, death was not attributed to other causes and evidence of suicidal ideation existed.
To understand the processes and identify patterns, all relevant case documentation regarding the complaint was reviewed using a methodology adapted from the NHS (England) SI framework [12]. This framework sets out the circumstances (what?), the contributing factors to the problem (how?) and the root cause(s)/fundamental issues (why?), and what could be done to stop this happening in the future. Each case was reviewed and synthesised with the interview data as described in Fig. 1.
Other elements of the work
There were two other elements of the work. Ahpra appointed an expert advisory group (EAG), including external members with expertise in regulation and suicide prevention, to guide the project. The EAG met nine times. Second, to ensure that the voices of those closest to the day-to-day work were involved, researchers held four workshops with regulatory staff to discuss emerging themes, present preliminary research findings, explore views, and discuss recommendations for improvement. The spouse of a practitioner who died by suicide, while involved in a complaints process with Ahpra also met with the EAG and participated in a workshop with staff, providing their lived experience and suggestions for improvement.
Results
This section describes the results from the interviews and SI analysis.
Practitioner interviews
There were 228 practitioners contacted and 22 (9.6%) participated in the interviews, which lasted an average of 29.48 min (range 19–53 min). Participant characteristics are presented in Table 1.
Participant characteristics.
| Sex | |
|---|---|
| Male | 14 |
| Female | 8 |
| Age | |
| Under 30 | 1 |
| 31–50 | 8 |
| 51+ | 13 |
| Profession | |
| Medical practitioner | 9 |
| Nurse | 4 |
| Psychologist | 4 |
| Dentist | 2 |
| Paramedic | 1 |
| Chinese medicine practitioner | 1 |
| Physiotherapist | 1 |
| Type of complaint or concern | |
| Clinical performance | 12 |
| Health impairment | 6 |
| Professional conduct | 4 |
| Outcome of matter | |
| Regulatory action taken | 15 |
| No regulatory action taken | 7 |
| Sex | |
|---|---|
| Male | 14 |
| Female | 8 |
| Age | |
| Under 30 | 1 |
| 31–50 | 8 |
| 51+ | 13 |
| Profession | |
| Medical practitioner | 9 |
| Nurse | 4 |
| Psychologist | 4 |
| Dentist | 2 |
| Paramedic | 1 |
| Chinese medicine practitioner | 1 |
| Physiotherapist | 1 |
| Type of complaint or concern | |
| Clinical performance | 12 |
| Health impairment | 6 |
| Professional conduct | 4 |
| Outcome of matter | |
| Regulatory action taken | 15 |
| No regulatory action taken | 7 |
Participant characteristics.
| Sex | |
|---|---|
| Male | 14 |
| Female | 8 |
| Age | |
| Under 30 | 1 |
| 31–50 | 8 |
| 51+ | 13 |
| Profession | |
| Medical practitioner | 9 |
| Nurse | 4 |
| Psychologist | 4 |
| Dentist | 2 |
| Paramedic | 1 |
| Chinese medicine practitioner | 1 |
| Physiotherapist | 1 |
| Type of complaint or concern | |
| Clinical performance | 12 |
| Health impairment | 6 |
| Professional conduct | 4 |
| Outcome of matter | |
| Regulatory action taken | 15 |
| No regulatory action taken | 7 |
| Sex | |
|---|---|
| Male | 14 |
| Female | 8 |
| Age | |
| Under 30 | 1 |
| 31–50 | 8 |
| 51+ | 13 |
| Profession | |
| Medical practitioner | 9 |
| Nurse | 4 |
| Psychologist | 4 |
| Dentist | 2 |
| Paramedic | 1 |
| Chinese medicine practitioner | 1 |
| Physiotherapist | 1 |
| Type of complaint or concern | |
| Clinical performance | 12 |
| Health impairment | 6 |
| Professional conduct | 4 |
| Outcome of matter | |
| Regulatory action taken | 15 |
| No regulatory action taken | 7 |
Themes from the interviews with practitioners were collated under:
factors contributing to distress (C1–4) or
protective factors (P1–3).
Notable contributors to distress were the ‘insult’ of the complaint itself (C1), communication issues with Ahpra (C2), time taken to close the complaint (C3), and external factors and pre-existing conditions (C4). The salient protective factors for practitioners were support systems. The major protective factors were support from family and friends (P1), support from practitioner representatives and other health professionals (P2), and positive interactions with Ahpra (P3). Example quotes supporting these themes are presented in Supplementary Table S1.
The ‘insult’ of the complaint (C1)
Practitioners commonly described the experience of having a complaint made about them, in and of itself, as distressing and affecting their wellbeing. One described it as ‘virtually daily grief but I managed it, you know. It didn’t make me sleep poorly, it didn’t give me an ulcer, but it was in the background the whole time’.
Other practitioners saw one complaint effectively negating years of good practice and thus casting a shadow over their entire career. One described how ‘I set up a bulk billing practice back when I came out from uni, worked really hard, did everything, tried not to charge people money … see people for free when Medicare ran out you know, all that sort of thing. So, that’s the sort of practice, tried really hard to help people, well, I would bend over backwards … somebody puts in a complaint, and the 10–12 years of knocking yourself out is completely irrelevant’.
Practitioners frequently referred to feelings of self-doubt, injustice, and loss of hope. For example, one described this as ‘being a nurse is something that I mean I identify with … and to find yourself in a place where I believed I allowed myself to fail, was really horrible.’ Some practitioners described the complaint about them as unjustified, minor or undeserving of investigation. Others felt the lack of scrutiny of the notifier—including sometimes preserving notifier anonymity—highlighted a bias against them. Distrust of Ahpra was reported, often described in the context of their view of the overall unfairness of the complaint being accepted at all.
‘Our lecturers always warned us about Ahpra notifications … in my mind it was always like this kind of scary thing. I was scared that Ahpra would just immediately take the patient’s side and then kind of gang up against me.’
Communication issues with Ahpra (C2)
Practitioners underscored the importance of regular and transparent communication with Ahpra. Concerns were linked to uncertainty and confusion about the process, tied to a lack of information, unclear timelines, and no indication of likely outcomes. One practitioner described this as ‘it seemed that there was no way to understand when or what was happening in the background’.
Practitioners described phone calls and emails going unanswered or delays in responses. The perceived lack of responsiveness contributed to the sense that the process was out of their control. A comment from one, ‘sitting around not knowing and waiting for an email, was … absolutely gut-wrenching, you know?’
This generated a fear of the unknown, with practitioners not knowing where it was going to end and unable to avoid assuming the worst-case scenarios. Another commented, ‘It was one of those frustrating things where everything was not directly with anyone. So, anything you did had to be either through email and then you had to wait for the response. And so, it’s frustrating ‘cause it wasn’t immediate. You could not get you know—everything out’.
Participants consistently reported that better communication, for example, if they had been given some early indication about how serious the complaint was and whether a serious regulatory outcome was likely, would have improved their experience considerably.
Time taken to close the complaint (C3)
Many practitioners raised the length of time taken to close their complaint, citing the ongoing emotional and practical repercussions while the complaint was open. One participant described this as ‘it dragged on over years, so you’d literally be sitting in a cold sweat every day, just looking through emails waiting for the next message to come from Ahpra, which was invariably bad news’.
Another said, ‘… I’m sure you’ll hear from most people, the stress is in the—the most significant stress is in the waiting’.
Practitioners mentioned the unfairness of ‘double standards’, where the time allowed for them to respond or provide information was short, contrasted with long gaps in correspondence from Ahpra.
External factors and pre-existing conditions (C4)
External factors in the practitioner’s environment and personal situation significantly influenced experiences of distress. For those practitioners with a health-related concern, most commonly a mental health or substance use disorder, the protracted process, lack of control, and loss of hope of practising again, compounded their existing health issue.
Internationally qualified practitioners pointed to cultural differences affecting their stress levels and the additional challenges they faced, particularly a lack of professional and personal support. One participant said ‘I have no family here. I have not anyone to help me. I have no one to guide me where to go. It was very difficult really … I understand if an Australian person it would be easier; they have families, they have people around them, friends, someone maybe has been through this process so they can ask them. But for me it was like I’m dying. Where—who can help me?’
Some practitioners described parallel stressors occurring alongside the regulatory process, often linked to it. For example, the event causing the complaint may have resulted in a temporary or permanent loss of employment. One commented, ‘there was a lot of other stuff going on … the business had failed, I was being chased by a landlord for money I didn’t have, and only actually sold my house and everything involved. I was under an enormous lot of pressure at the time, and it was just like there was—it was just too much’.
Additionally, in cases where information about the complaint became public in the context of a tribunal process, media reporting greatly amplified the practitioner’s distress. Another said, ‘[the journalist] … put me in the front page with my picture and my name, my nationality, everything, my job. So that—that, I could say, trebled the stress’.
Support from family and friends (P1)
Support from family, friends, and colleagues was a clear protective factor, with most practitioners speaking of the essential role of their close personal networks. Many sought emotional support from family and friends, particularly in reacting to news of the complaint. For example, one commented that they had ‘a very good network of friends and support people and so I have plenty of things to fall back on.’ ‘Because of having the support, with family and with [partner], the process wasn’t too hard at all.’
It was not uncommon for practitioners to speculate on the extreme difficulty they might have faced without a network of family or friends to rely on. Some described the regulatory process as also having a detrimental impact on those closest to them.
Support from practitioner representatives and other health professionals (P2)
Practitioner representatives, such as legal defence organisations and indemnity providers, were regularly mentioned as improving the process and providing knowledge and expertise, helping practitioners to cope with and better understand the process. One participant commented, ‘the medical indemnity service … they were back to me pretty quickly, they were very supportive, so it wasn’t a problem’.
Support from GPs and mental health practitioners, as well as connecting with other practitioners with similar experiences, were identified as helpful for managing distress through the complaint. Where colleagues or managers were aware, they were often noted as providing important support. For example, ‘My bosses have been through things like this before. Our clinic that we work at is pretty big, so there was [sic] multiple practitioners and they reassured me, they were like “Look everyone’s gone through this or will go through this so don’t worry we will help you; you didn’t do anything wrong”.’
Some practitioners did not access support; despite feeling distressed, they were fearful of the reaction of others or thought it would not help them. These practitioners commonly stated that they were not the ‘type of person’ to reach out for support, formal or informal.
Positive interactions with Ahpra (P3)
Interviewed practitioners often mentioned the importance of empathy, sensitivity, and regular communication from Ahpra staff, noting that these helped to minimise their distress. Where there was an initial phone call informing the practitioner of the complaint, this was frequently described as a positive approach to relaying difficult news. For example, one said ‘I knew I did nothing wrong, and I knew that I didn’t have anything to worry about but just the fact that she was like “I just wanted to reassure you that you are not in trouble, we just want to get your side of the story” and she was just—she was just really nice to me, you know, and she empathised with me as well, which I found really helpful as a practitioner.’
Although interactions with staff were also recognised as a contributor to distress, practitioners were more likely to speak positively when they referenced specific staff. This compared to more generic references to communication issues (not regular or informative enough). Another observed, ‘Before I even had a letter or an email or a notification from Ahpra, somebody called me. They were very nice, they were not blaming me, they were not really accusing me. Their language was very mindful in that way, so they didn’t say things like “you are being accused of blah, blah, blah, blah, blah”, or “we’re investigating because you have done this and that and that” … it was less aggressive and confronting.’
However, despite the benefit of empathetic communication by staff, this was usually not enough to mitigate factors like uncertainty, long timeframes or the threat of deregistration.
Serious incident analysis
Researchers identified 20 cases over 4 years where practitioners who were currently, or recently, involved in a regulatory process had attempted suicide or self-harm or had taken their own lives. (see Table 2) Of the 20 cases, 16 resulted in death and 4 were attempted suicide or self-harm. Of the 16 deaths, 12 were confirmed suicide and 4 were deemed likely suicide based on the information available. The focus of the case reviews was on understanding any contribution of regulatory processes to practitioner stress and distress. The case reviews did not aim, or have sufficient information, to determine the reasons behind practitioner deaths.
Characteristics of practitioners involved in serious incidents.
| Sex | |
|---|---|
| Male | 13 |
| Female | 7 |
| Age | |
| Under 30 | 3 |
| 31–50 | 10 |
| 51+ | 7 |
| Profession | |
| Medical practitioner | 8 |
| Nurse | 8 |
| Other professions | 4 |
| Type of complaint or concern | |
| Clinical performance | 0 |
| Health impairment | 6 |
| Professional conduct | 8 |
| Health impairment and professional conduct | 6 |
| Outcome of matter | |
| Regulatory action taken | 12 |
| Outcome not yet determined at time of serious incident | 8 |
| Sex | |
|---|---|
| Male | 13 |
| Female | 7 |
| Age | |
| Under 30 | 3 |
| 31–50 | 10 |
| 51+ | 7 |
| Profession | |
| Medical practitioner | 8 |
| Nurse | 8 |
| Other professions | 4 |
| Type of complaint or concern | |
| Clinical performance | 0 |
| Health impairment | 6 |
| Professional conduct | 8 |
| Health impairment and professional conduct | 6 |
| Outcome of matter | |
| Regulatory action taken | 12 |
| Outcome not yet determined at time of serious incident | 8 |
Characteristics of practitioners involved in serious incidents.
| Sex | |
|---|---|
| Male | 13 |
| Female | 7 |
| Age | |
| Under 30 | 3 |
| 31–50 | 10 |
| 51+ | 7 |
| Profession | |
| Medical practitioner | 8 |
| Nurse | 8 |
| Other professions | 4 |
| Type of complaint or concern | |
| Clinical performance | 0 |
| Health impairment | 6 |
| Professional conduct | 8 |
| Health impairment and professional conduct | 6 |
| Outcome of matter | |
| Regulatory action taken | 12 |
| Outcome not yet determined at time of serious incident | 8 |
| Sex | |
|---|---|
| Male | 13 |
| Female | 7 |
| Age | |
| Under 30 | 3 |
| 31–50 | 10 |
| 51+ | 7 |
| Profession | |
| Medical practitioner | 8 |
| Nurse | 8 |
| Other professions | 4 |
| Type of complaint or concern | |
| Clinical performance | 0 |
| Health impairment | 6 |
| Professional conduct | 8 |
| Health impairment and professional conduct | 6 |
| Outcome of matter | |
| Regulatory action taken | 12 |
| Outcome not yet determined at time of serious incident | 8 |
Themes from serious incident case analysis
The key themes emerging from the SI analysis were pre-existing vulnerabilities (SI-1), regulatory management of health concerns by Ahpra (SI-2), trigger points (SI-3), communication and coordination issues (SI-4), and post-incident actions (SI-5).
Pre-existing vulnerabilities (SI-1)
Most practitioners who died by suicide had pre-existing mental health issues or a history of a substance use disorder or both. Mental health diagnoses included depression, anxiety, and post-traumatic stress disorder.
A small subgroup of practitioners was facing serious criminal or misconduct allegations. In these circumstances, the conduct and/or the likely consequences associated with it (criminal prosecution, community shaming, media reporting, and loss of professional standing) appeared to be predominant factors in their distress.
Regulatory management of health concerns (SI-2)
The case reviews suggested that Ahpra’s approach to managing health-related concerns was inconsistent. There was not a systematic approach to identifying, prioritising, and managing the unique risks of these practitioners.
In some cases, staff appeared to be very mindful of the practitioner’s wellbeing, attempting to follow-up or move cases along. However, researchers also found health concerns where once regulatory action was taken, such as suspension, the case was delayed for long periods. In some matters, staff appeared aware of the need for additional support for practitioners with a mental health concern or substance use disorder, but there did not appear to be a systematic approach, for example, for escalating identified risks of self-harm or suicide.
Trigger points (SI-3)
Trigger points appeared to be particularly distressing for practitioners. These included the initial letter or telephone call informing them of the complaint, a decision to suspend, receiving the results of an independent health assessment, and a decision to refer to a tribunal. There were examples of each situation, of practitioners attempting or dying by suicide shortly after the trigger point.
Communication and coordination issues (SI-4)
Ahpra communication with practitioners throughout the cases reviewed was seen as impersonal, legalistic, and lengthy. On multiple occasions practitioners sought feedback from Ahpra on timeframes or challenged the practicality of compliance conditions. While there were also timely and sensitive communications and, in general, good records, there was variability across the 20 cases that researchers reviewed, and with substantial variation in the approach taken by different staff. Communication regarding immediate action suspensions was of particular concern, especially when the practitioner did not appear to have a support network or lawyer. Interactions were often through the practitioner’s lawyer, at times obscuring the ability of Ahpra staff to see what was unfolding in the practitioner’s life.
Post-incident actions (SI-5)
The analysis revealed only an embryonic approach within Ahpra to systematically reflect on or consider relevant changes or improvements following an attempted suicide or death by suicide. There did not appear to be a uniform process for debrief following a death, a record of the debrief including lessons learned or the feedback loop to training. There was also limited evidence of organised support for staff or involved Board members following such an incident beyond the offer of access to employee support services.
Discussion
This project sought to understand the factors associated with the distress experienced by practitioners when involved in a regulatory process. The findings suggest there are specific steps that could be taken by Ahpra in partnership with others, and which have relevance to regulators worldwide. These improvements can be made while continuing to prioritise public safety.
The EAG made a comprehensive set of recommendations and associated actions all aimed at minimising distress, particularly for those practitioners who are unwell or otherwise at risk of harm. All were accepted by the regulator and will be implemented over the next 12–24 months. The recommendations/actions are included in Appendix 1.
Statement of principal findings
The results from both the interviews and the SI analysis highlight elements of the regulatory complaints process contributing to practitioner distress which could be improved.
They include ensuring regular and consistent communication, timeliness, targeted management of health-related concerns and systemic learning from SIs. Some of these elements require appropriate training, support for staff and decision-makers, and a stronger focus on timely and consistent empathic communication. Others require a tailored and thoughtful approach to managing those practitioners whose health impairment has brought them to the attention of the regulator and who are at heightened risk to themselves.
The findings also point to the need for improved partnerships between regulators and key stakeholders, such as employers, legal defence organisations, indemnity providers, and those with lived experience of complaints to consider the support needed for practitioners facing a complaint. Understanding, identifying, and acting on the risk of self-harm require whole system responses. Increasing awareness within the wider health system of the stigma, stress, shame, loss, and alienation experienced by practitioners who have a complaint made about them must lead to improved support networks—from colleagues, employers, and treating practitioners—at a time in the practitioner’s life when it is most needed.
Interpretation within the context of the wider literature
The results align with published findings in other regulatory contexts [1–3, 5, 9]. Previous research has highlighted the negative impact of the complaints process [1, 5], and discussed the need to improve communication, transparency, and empathy [3, 5], as well as better collaboration between organisations [5]. Brooks et al. (2014) suggest a more supportive approach would lead to better outcomes, while Maben et al. (2021) point to the need for better signposting for support and greater consideration of the context in which a complaint arises. The recommendations from this work extend this further, embedding targeted approaches for improved complaints processes.
Implications for policy, practice, and research
Health practitioner regulators around the world must maintain their focus on protecting the public from harmful practice. Poor clinical performance, deliberate harm or intent to deceive must be identified and addressed in a timely, fair, and robust way to address risk to patients. However, this research adds to previous research [1, 13–16], which point towards the need for a more nuanced and humane model of regulation, particularly in cases where there is a potentially high risk of distress or harm to practitioners facing a complaint. Replicating this work in other countries would add to the evidence base and determine what impact such an approach might have elsewhere. This could also help to reduce systemic [17], unintended impacts of regulation on a pressured and ever diminishing workforce [18, 19], who we know are at increased risk of suicide [14, 20, 21], while maintaining quality and high standards of healthcare for all patients.
Strengths and limitations
There were several limitations to the design of the work. Practitioners involved in interviews were a self-selecting group. Like other qualitative studies of this nature, numbers were small, and selection bias may limit the transferability of the findings.
Although the documentation included in the SI analysis was extensive, it related to regulatory documentation and, therefore, did not include all relevant information about the practitioner. Finally, although every attempt was made to seek out all cases involving practitioners who had self-harmed or died by suicide, there may be additional incidents about which Ahpra was unaware.
Conclusion
Health practitioner regulators are mandated to protect the public; however, this does not preclude a simultaneous concern for the wellbeing of practitioners [9]. There are elements of the regulatory complaints process that can be improved. Some contributors to practitioner distress require a systemwide, preventative approach, including addressing stigma and misinformation. A more compassionate approach to regulation has the potential to improve the experience for all those involved and, ultimately, benefit patients, families, practitioners, and the global healthcare system.
Acknowledgements
The authors would like to thank Gabrielle FitzGerald for her commitment and support throughout this project, Tess Moloney for her helpful pedantry, and Dr Ruth Riley for her comments on an earlier draft of the paper.
We would also like to thank participants and staff who took part in the study, and in particular those who took time to reflect on life events which caused them distress. We would also like to acknowledge those who have lost loved ones in situations of extreme distress and hopelessness.
Author contributions
Susan Biggar (design of the qualitative work and synthesis of the data [equal]; conducted interviews [equal]; reviewed and developed themes for SI documentation [equal]; with significant input from Martin Fletcher and Anna van der Gaag led drafting of the manuscript; Sarah Anderson and Jacinta Evans also participated in editing and finalisation of the manuscript; Martin Fletcher (design of the qualitative work and synthesis of the data [equal]); Kim Ayscough and Matthew Hardy (design of the qualitative work and synthesis of the data [equal]); Manaan Kar Ray (design of the qualitative work and synthesis of the data [equal]); Pat Maher (design of the qualitative work and synthesis of the data [equal]; conducted interviews [equal]; reviewed and developed themes for SI documentation [equal]); Rachel Phillips (design of the qualitative work and synthesis of the data [equal]); Catherine Schofield (design of the qualitative work and synthesis of the data [equal]); Anne Tonkin (design of the qualitative work and synthesis of the data [equal]); Anna van der Gaag (design of the qualitative work and synthesis of the data [equal]; reviewed and developed themes for SI documentation [equal]); Jacinta Evans (led the work to analyse and interpret the interview data, overseen by Sarah Anderson and Eva Saar [equal]); and Lakshmi Bondu (led the work to analyse and interpret the interview data, overseen by Sarah Anderson and Eva Saar [equal]).
Supplementary data
Supplementary data is available at INTQHC online.
Funding
This work was supported by the Australian Health Practitioner Regulation Agency as part of its quality improvement work.
Approval
Two applications for ethical approval, one for the practitioner interviews (#82390) and the other for the SI analysis (#84222), were submitted to the Prince Charles Hospital Human Research Ethics Committee, Metro North Hospital and Health Service, Brisbane, Australia. Both applications were approved following one round of amendments.
Data availability
The data underlying this article cannot be shared publicly due to the sensitive nature of the information and to protect the identities of those involved.
References
Appendix 1: Ahpra Recommendations
(Continued)
(Continued)
(Continued)
Author notes
Handling Editor: Prof. David Greenfield.
