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| Journal of the New Zealand Medical Association,
19-September-2008, Vol 121 No 1282
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|
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.
MethodStudy 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
Scale:
1=encountered behaviour once
2=once a month
3=once a week
4=>once a week
5=every day
ResultsWe 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)
 DiscussionOur 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
References:
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