Bullying in the workplace

How to discourage bullying and harassment

While most physicians are caring, collaborative people who go into medicine to help others, that care is not always extended to trainees, colleagues and subordinates. The result: a profession in which bullying is a major problem. 

In the Resident Doctors of Canada’s national survey, more than three-quarters of medical residents said they had experienced harassment or intimidation in the past year.

Trainees are particularly vulnerable to abuse because physicians can hold so much power over them. This power structure also affects other marginalized populations, including colleagues taking maternity leave and individuals belonging to a minority.

What bullying in the medical profession looks like

Bullying in the medical profession can take many forms, including any or all of the following disruptive and psychologically abusive behaviours:

• Aggression, hostility, shouting, threats or intimidation
• Rudeness or disrespect
• Public criticism, shaming, berating or “pimping” (rapid-fire questions or deliberately demanding answers above a student’s knowledge level)
• Uncontrolled anger or tantrums
• Discrimination, ostracization, exclusion or gossip
• Passive aggression or sarcasm
• Misuse of power
• Sexual harassment
• Offensive jokes

Bullying can cause stress, fatigue, presenteeism, anxiety, burnout, depression, substance abuse, broken relationships, early retirement and even suicide. It can affect performance, self-esteem/self-confidence, absenteeism and teamwork. It can also directly affect patient safety and quality of care.

One study in the Journal of the American Academy of Pediatrics showed teams treated rudely by an “expert observer” performed much worse in a simulated situation compared to teams treated respectfully. They shared less information and didn’t seek help as often, which led to poorer clinical outcomes. Another survey from the Joint Commission Journal on Quality and Patient Safety found that 71% of doctors and nurses believe disruptive behaviour is linked to medical errors, and 27% believe it is linked to patient mortality. 

Bullying persists because it has been allowed to

The culture of medicine has long tolerated or ignored bullying behaviours — and that will not change until the problem is addressed at the leadership level. 

Factors that may lead someone to start bullying include:

• Lack of resources on fatigue management
• Stress
• Mental illness or substance abuse
• Heavy workload
• Personal issues (e.g., death of a loved one, financial difficulties) 
• Unrealistic self-image (e.g., seeing oneself as high-performing rather than domineering)

Bullying starts early in medical school and residency and has been called part of the “hidden curriculum” — that is, informal learning that falls outside the formal medical curriculum and takes place through unarticulated processes. In these informal settings, many students are questioned aggressively, shamed for lack of knowledge, ignored, belittled and disrespected. Yet these incidents are hard to prove and difficult to police because victims are made to feel responsible and powerless.

The effects of these negative teaching environments can be profound and enduring.

When expert advisors are hostile, learners and residents cannot feel safe approaching them for help to learn or for advice on how to manage patient care.

How organizations can reduce bullying and harassment in clinical settings

Ensure early and continuing education from medical school, through residency and into practice.

Advocate for medical schools to make ethics, communication and team building part of their curricula. Encourage educators to teach clear policies against abusive behaviour early in a physician’s professional journey.

Identify disruptive behaviour clearly so all staff understand what is considered unprofessional.

Evaluate students and staff regularly to ensure their behaviours are within professional expectations.

Create and follow a code of conduct to build a culture of safety and respect. (See an example in Appendix F in this guidance document.)

Promote good communication among clinical teams. When team members feel unable to speak up for fear of negative consequences, care can be compromised.

Hold briefings. Spend a few minutes before each shift to get everyone on the same page, avoid surprises and help the team work together using the SBAR approach:
•    Situation − What is going on with the patient?
•    Background − What is the clinical background or context?
•    Assessment − What do I think the problem is?
•    Recommendation − What would I do to correct it?

SBAR transmits critical information in a predictable structure and helps develop critical thinking skills. Click here for SBAR guidelines and worksheets. 

Teach appropriate assertion. This technique helps people speak up and express their concerns regardless of rank. Staff at all levels should be encouraged to state their concerns politely and persistently until they get an answer rather than speaking indirectly (“hinting and hoping”), and to focus on the problem rather than who’s right or wrong.

Create clear pathways for action to enforce behavioural standards: 

• Implement a confidential electronic reporting system to empower staff to speak up. Relay comments back to those involved to encourage self-reflection and correction. 
• Implement an anonymous patient advocacy reporting system so patients can report a clinician for dismissing their questions, rushing them or being rude to other staff members.
• Measure the effects of these programs on bullying and clinical outcomes.

See the Health Quality Council of Alberta’s framework and resource toolkit on managing disruptive behavior in the healthcare workplace for help with implementing these actions.

Workplace bullying is a serious and growing problem that affects a significant proportion of health care professionals. For the sake of physicians, patients and the profession, it’s time to foster collegiality and end the culture of bullying, harassment and intimidation in Canadian medicine.
 

Topics

Conflict management and prevention Stress Burnout Relationships Suicide Depression