Journal of the New Zealand Medical Association, 19-September-2008, Vol 121 No 1282
Workplace bullying of junior doctors: a cross-sectional questionnaire survey
Joanne Scott, Chloe Blanshard, Stephen Child
Workplace bullying has been recognised as a major occupational stressor since the early 1980s. However, bullying has become more recognised in the medical profession in recent years.1–3 Workplace bullying can have detrimental effects such as decreased job satisfaction, depression, anxiety, and absenteeism4 which impacts on staff retention and quality of patient care.
The recognition and management of bullying in the workplace is complicated by the lack of a consistent definition. It has been suggested by Rayner and Hoel that bullying can be defined as incorporating any of the following five key elements:
It is generally accepted that bullying incorporates negative behaviour(s) which are carried out repeatedly, rather than a single episode. It is not the perpetrator's intention, but instead the victim's perception, that determines whether the bullying has occurred.
Previous studies of UK junior doctors show that 37% have been bullied in the preceding year.5 An Australian study had this prevalence as high as 50%.6 More recently, an Irish study showed a rate of 30%.1 The studies show that the majority of bullying behaviours were from fellow doctors, in particular, those of greater seniority.
In this study, we attempted to determine the prevalence of bullying at Auckland City Hospital, which is the largest teaching hospital in New Zealand.
Study design—We conducted a cross-sectional survey of all house officers and registrars (registered medical officers—RMOs) working at a teaching hospital with just under 1000 beds.
An anonymous questionnaire was sent via internal mail to 141 house officers and 232 registrars. A self-addressed internal mail envelope was included.
The questionnaire collected information on the participant’s age, gender, postgraduate year, country of training, ethnicity, and whether they were doing a medical or surgical run.
The participants were presented with a table of 14 bullying behaviours (Table 1). They were asked to identify whether they had experienced any of the behaviours in their previous term (3- or 6-month clinical attachment). If they had, they were asked to identify the staff group who perpetrated the behaviour and rate on a scale of 1–5 how frequently they encountered the behaviour.
If they had experienced any bullying behaviours, they were asked whether they had made a formal complaint, and whether this was effective. If they did not make a formal complaint, they were asked why they did not.
Statistics—All analyses were performed using SAS (SAS Institute Inc, v9.1) software. Continuous normally distributed variables were compared using Student’s unrelated groups test and Chi-squared analysis was used for categorical data. All tests were two-tailed and p<0.05 was considered statistically significant.
Table 1. Questionnaire
1=encountered behaviour once
2=once a month
3=once a week
4=>once a week
We had a response rate of 34% (48/141) from house officers and 32% (75/232) from registrars. 50% (186/373) of these doctors reported at least one episode of bullying behaviour (95%CI: 41–58%, p=0.047).
50% (93/186) of those who were bullied were either first-year house officers, or first-year registrars (p value=0.008). There was a trend for RMOs doing a surgical run to report a higher incidence of at least one bullying behaviour compared to those doing a medical run (59% [27/46] vs 44% [27/62], p=0.17).
RMOs under the age of 25 reported bullying more frequently than those over the age of 25 (72% [17/24] vs 44% [43/99], p=0.024). There were no differences in gender, ethnicity, or whether the RMO was trained in New Zealand or overseas.
Consultants and nurses were the main perpetrators of bullying behaviour (30% [63/214] each) followed by patients (25% [53/214]), radiologists (8% [18/214]), and registrars (7% [17/214]) (Figure 1). Registrars were more often bullied by consultants, and house officers by nurses.
Figure 1. Who does the bullying?
The most widespread bullying behaviour encountered was unjustified criticism from consultants, followed by ’undervaluing of efforts’ (Figure 2).
Only 18% (33/186) of those who had experienced at least one episode of a bullying behaviour made an official complaint. 63%(20/33) of those who complained were house officers, and 83% (27/33) were female (p=0.042). Of those who made a complaint, 54% (18/33) reported some improvement. Of those people who did not make an official complaint, 82% (125/153) were not sure how to complain, and 79% (121/153) were afraid of the consequences. 72% (134/186) of those who had been bullied dealt with it themselves.
Figure 2. Most common bullying behaviour (total complaints = 214)
Our study indicates that junior doctors at Auckland City Hospital perceive that they are bullied at the same prevalence rate as similar studies performed overseas.1,3,5,6 Studies such as this, however, suffer from problems of definition, perception, and response bias.
Bullying is clearly a difficult behaviour to define. It must be recognised that the medical education system is a hierarchical, high-pressure environment in which differences in knowledge often lead to an imbalance in power. In such an environment it would be common for performance feedback to be misinterpreted as bullying rather than a misguided attempt to improve performance.7 Irrespective of these qualifying factors, the perception of the victim is still the most important aspect of bullying behaviour. Secondly, in our study, junior doctors have identified instances where they have been bullied on a single occasion which would not meet the accepted definition of bullying.
Finally, the presentation of bullying behaviours in the survey may have prompted respondents to declare bullying behaviours and those who are bullied are possibly more likely to respond (i.e. responder bias).
Despite this, it is reassuring (although still totally unacceptable) that the prevalence of bullying amongst medical staff at our hospital when measured by similar methods and limitations is in line with the reported prevalence (30–50%) as defined from other overseas studies.1,3,5,6
In addition, this study identifies two further issues. Firstly, while our medical personnel may be accused of bullying due to the hierarchical nature of the education structure, it is difficult to explain the high frequency of bullying by nurses towards house officers. Secondly, the majority of doctors who had experienced bullying behaviour did not complain and 79% stated that they were afraid of complaining. This is in line with a study by Dickson in which he states, “It is not that the victim cannot complain; it is that they perceive themselves as helpless or they perceive the consequences of complaining as worse than the status quo.”8
While the bullying behaviour may not have been of sufficient stature to warrant a formal complaint it is still a major concern that a significant number of doctors did not know the process by which they could address the issue. In contrast, however, it was reassuring to note that 54% of those that did complain noted an improvement which somewhat validates our current processes.
In summary, our study has identified a high prevalence of perceived bullying by junior doctors. While the bullying may be a misperception by the victim, it is still of sufficient concern that it requires further study. Organisational support should be given to all employees to minimise such behaviour and support potential victims. We recommend training sessions on effective communication and delivery of constructive criticism for the main perpetrator groups identified in this study. Possibly a formal complaint process should be identified with a standardised format, open accessibility, and confidentiality restrictions. Following these interventions, a repeat study should be conducted to confirm a positive change in bullying behaviours.
Competing interests: None known.
Author information: Joanne Scott, House Officer, Department of General Medicine, Auckland City Hospital, Auckland; Chloe Blanshard, House Officer, Department of General Medicine, Auckland City Hospital, Auckland; Stephen Child, Director of Clinical Training, Clinical Education and Training Unit (CETU), Auckland City Hospital, Auckland
Acknowledgements: We thank David Spriggs (Clinical Director, Department of General Medicine, Auckland City Hospital, Auckland); Gill Naden (Manager, CETU, Auckland City Hospital, Auckland); and Medical Council of New Zealand for their assistance.
Correspondence: Dr Stephen Child, CETU, Level 15, Support Building, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand. Fax: +64 (0)9 6236421; email: StephenC@adhb.govt.nz
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