Open Access
Abstract
The
2012 General Medical Council National Trainees' Survey found that 13%
of UK trainees had experienced undermining or bullying in the workplace.
The Association of Surgeons in Training subsequently released a
position statement raising concerns stemming from these findings,
including potential compromise to patient safety. This article considers
the impact of such behaviour on the NHS, and makes recommendations for
creating a positive learning environment within the NHS at national,
organisational, and local levels. The paper also discusses the nature of
issues within the UK, and pathways through which trainees can seek
help.
Keywords
- Undermining bullying surgical training workplace
Abbreviations
- AoME, Academy of Medical Educators;
- ARCP, Annual Review of Competence Progression;
- ASiT, Association of Surgeons in Training;
- BMA, British Medical Association;
- FST, Faculty of Surgical Trainers;
- GMC, General Medical Council;
- IRM, Invited Review Mechanism;
- JCST, Joint Committee on Surgical Training;
- JDC, Junior Doctors Committee;
- LETB, Local Education and Training Board;
- RCOG, Royal College of Obstetricians and Gynaecologists;
- RCSEng, Royal College of Surgeons of England;
- RCSEd, Royal College of Surgeons of Edinburgh
1. Introduction
As
professionals, surgical trainees have a reasonable expectation to feel
valued and safe in the workplace. The General Medical Council's (GMC)
national training survey in 2012 demonstrated excess rates of
undermining and bullying of surgical trainees compared with trainees
from other specialities
[2].
As a result, the Association of Surgeons in Training (ASiT) released a
position statement in July 2013 highlighting this important issue
[1].
ASiT's remit is to promote excellence in surgical training and whilst
bullying in the workplace may be considered to be the remit of other
bodies, such as the GMC and British Medical Association (BMA) Junior
Doctors Committee (JDC), undermining and bullying has a fundamental
impact on training. Individual trainees have approached ASiT, often
anonymously, raising concerns of a bullying culture within their
surgical departments and how this has a detrimental impact on the
training environment. The objective of this article is to summarise the
issues surrounding undermining and bullying within a surgical training
environment, and the potential consequences of that behaviour, if it is
allowed to persist within a surgical workplace. The article also
summarises the guidance and pathways available to surgical trainees in
order to appropriately raise concerns over undermining and bullying, and
aims to clarify what actions ASiT would expect from national
organisations, Deaneries, Local Education and Training Boards (LETBs),
Trusts and departments of surgery in order to address this important
issue.
2. Undermining and bullying: an occupational hazard
Despite
the fact that a caring nature is a prerequisite to the successful
practise of medicine, undermining and bullying of trainees has been a
familiar feature of the medical professional culture in the NHS for many
years
[3],
[4],
[5] and
[6], with workforce bullying described as an “occupational hazard” for junior doctors
[7].
In 2012, the GMC first included undermining as an indicator in their
annual national training survey and subsequently published their first
dedicated report on undermining and bullying
[2].
This revealed that 13% of trainees had been victims of bullying and
harassment, with 20% having witnessed someone else being bullied. These
findings have been echoed in subsequent GMC national training surveys
[8] and
[9],
with issues of undermining and bullying of trainees identified in
seventy-four NHS sites across the UK, with seven sites under enhanced
monitoring
[10].
Reviews of quality and safety at individual institutions have
highlighted undermining and bullying of junior medical staff as a
significant issue
[11].
The problem is not restricted to the United Kingdom, with similar
reports of bullying of residents in the Irish, and North and South
American healthcare systems
[12],
[13],
[14] and
[15].
Workforce
bullying does not only affect junior doctors, and is an unfortunate
theme throughout the NHS, with the high level of personal involvement in
their jobs putting healthcare workers at an increased risk of bullying
[6].
The 2014 NHS Staff Survey revealed that 24% of staff reported that they
had experienced bullying, harassment or abuse from either their line
manager or other colleagues. Concerns over a culture of bullying in the
NHS have been voiced by health service leaders
[16] and
[17],
with a bullying culture identified as a major contributor to the
notable care failings detailed in the Mid Staffordshire enquiry
[18]. Within evidence submitted by individuals or organisations to the subsequent
Freedom to Speak Up [19] review of whistleblowing in the NHS, a greater number of references were made to bullying than to any other problem raised.
3. What are the definitions of undermining and bullying?
The terms ‘
undermining’ and ‘
bullying’ are complex issues which can take many forms at individual, group, and organisational levels
[20].
Undermining and bullying can be difficult to characterise, with the
reported prevalence of such behaviours dependent on their definition and
the subjective opinions of respondents to surveys on the subject.
Undermining
is conduct that subverts, weakens or wears away a person's confidence,
and may occur when one practitioner intentionally or unintentionally
erodes another practitioner's reputation or intentionally seeks to turn
others against them. The GMC attempts to define bullying as ‘
words, actions or other conduct that ridicules, intimidates or threatens and affects individual dignity and well-being’
[21].
Bullying can include, but is not limited to, behaviours such as:
aggression, including threats; shouting abuse, obscenities and shouting
at people to get work done; persistent humiliation, ridicule or
criticism in front of patients, colleagues or in isolation; engaging in
malicious rumours; unjustifiably changing areas of responsibility and
relegating people to demeaning and inappropriate tasks; deliberately
excluding an individual from discussions or decisions and aggressive
communication in any form, including electronic communication and
cyberbullying
[7].
Bullying can be subjective, and those regarded as bullies by colleagues
often do not perceive themselves as such and rather they see themselves
as applying “firm leadership”, “being decisive” or even “having a sense
of humour”
[19].
Undermining and bullying behaviours reported by trainees in the most recently published GMC national training survey
[9]
include being exposed to belittling, humiliating, threatening, or
insulting behaviour,or deliberately being prevented access to training.
Incidences of the bullying of trainees are relatively rare, however
undermining appears to be more common. In the vast majority of cases,
consultant and general practitioner trainers, rather than managers, were
identified as those responsible for the bullying and undermining
behaviour towards trainees. However undermining and bullying does not
solely occur between senior doctors and trainees. It should be
recognised that it can occur between trainees of similar or different
levels, and particularly between different allied healthcare
professionals, such as junior doctors, nurses and midwives
[22].
4. The implications of undermining and bullying of trainees
While
undermining and bullying of trainees is likely to have an adverse
impact on the individual exposed to such behaviour, it also negatively
impacts at an organisational level, and has serious implications on
patient care and safety. Trainees exposed to bullying can suffer from
mental and physical ill health and more likely to be absent from work
due to sick leave
[23].
Bullying and harassment in the workplace also creates a poor learning
environment with trainees suffering from a lack of confidence and
insecurity in their clinical skills, whilst fostering negative attitudes
towards the speciality in which they are training
[24].
By taking into account absenteeism, turnover and reduced productivity
it has been estimated that the annual cost of bullying to organisations
in the UK is £13.8bn
[25].
Undermining and bullying of trainees is likely to have a significant
financial cost at an organisational level in the NHS, but beyond the
personal and financial costs, bullying of trainees also has a
detrimental effect on patient care and safety. Bullying can result in
dysfunctional clinical teams that fail to communicate effectively
resulting in sub-optimal care. As front-line NHS staff, trainees occupy
an organisational space in which they witness both good and bad practice
first hand. Trainees therefore have an important role in raising
concerns over patient safety, however trainees can be deterred from
reporting such concerns due to a bullying culture
[19]
or non-receptive seniors. It is especially difficult for trainees in
smaller sub-specialities and in isolated geographical training areas to
raise concerns due to the potential lack of anonymity and subsequent
fears of victimisation and reproach
[10]. As described by Robert Francis QC, trainees are “valuable eyes and ears”
[18]
in the NHS, and therefore concerns raised by trainees should be
appropriately investigated. A toxic culture that undermines such
reporting negatively impacts patient safety.
Failure
to modify bullying behaviour should always lead to disciplinary action,
with harassment, bullying and victimisation being, in the eyes of the
law, forms of discrimination and therefore unlawful. Serious harassment
may also be a criminal offence. Incidents of this kind are subject to
the GMC's
Dignity at Work Policy [21]
with guidance stating that they will be dealt with under the GMC's
Disciplinary Procedure, and could lead to dismissal in serious or
repeated cases. ASiT recognises the significant repercussions that can
result for both victims and perpetrators as a result of an
investigation. Procedures exist, through the GMC and LETBs, for the
identification of placements and specialities that permit an environment
of undermining or bullying to exist. However, repeated identification
of ongoing issues raises concerns regarding their effectiveness.
5. A focus on surgical training
Reporting
of undermining and bullying varies widely between specialities. In
recent GMC national training surveys multiple training levels within
surgical specialities, and in obstetrics and gynaecology, have been
flagged as outliers for the presence of undermining and bullying in the
workplace
[2],
[8] and
[9].
This observation is supported by a survey by the Royal College of
Surgeons of Edinburgh (RCSEd) which reported that 60% of trainees polled
had personally been at the receiving end of workplace bullying, with
nearly all (94%) having observed it. Just over a third of respondents
felt able to report it through the appropriate channels
[26].
Similarly, in a survey of ASiT members regarding their experiences of
whistleblowing and raising concerns over patient safety, 60% of trainees
reported previous concerns over the practices and behaviour of
colleagues, including witnessing bullying, with 60% of respondents also
in agreement that the hierarchy of the surgical profession impedes the
raising of concerns
[27].
Unfortunately, undermining and bullying behaviours have a long history in surgical training
[28] with belittling of trainees often accepted as a “salutary rite of passage”
[29],
with “surgical culture” offered as an excuse to accept certain
behaviours in the operating theatre that would not be tolerated in any
other circumstance, instead being labelled as harassment or
intimidation. Tantrums, swearing, throwing of surgical instruments and
even wrapping trainees' knuckles with metal forceps when sutures are
placed incorrectly are the extreme but are well recognised behaviours
witnessed on the surgical wards and in operating theatres over the
generations. Humiliating and undermining trainees in front of colleagues
when cases are presented at post-take ward rounds or trauma meetings,
and a lack of consideration and respect for surgical trainees from
anaesthetists, surgeons and theatre staff who prevent surgical trainees
from operating in order to finish cases more quickly, remain
commonplace. The Annual Review of Competence Progression (ARCP) panel is
often perceived by trainees as an adversarial process rather than a
mechanism to assess training progress and highlight good performance
[30],
and may also provide an opportunity for trainees to be intimidated or
humiliated by a panel of senior surgeons. This behaviour is driven by
the hierarchy of surgical education and a “transgenerational legacy”
[31]
with a cycle of abuse may develop, where the mistreated surgical
trainee goes on to become a consultant surgeon who then mistreats his or
her trainees.
There
are several other factors that may be implicated to explain why
undermining and bullying is more common amongst the surgical
specialities. When compared with other fields, surgery is a
high-pressure acute discipline with a high intensity workload and a
significant levels of clinical risk and litigation. There are also
significant out-of-hours commitments, often with distant supervision on a
background of financial restrictions and continued demands from a
target-driven service. Combined with the perfectionist characteristics
and directive leadership styles often found amongst consultant surgeons,
this creates a perfect storm for undermining and bullying to thrive in.
Stress, burn out and overload are factors that lead to underperformance
of trainers
[32] with bullying being one manifestation of poor performance
[33].
As
discussed above, definitions and perceptions of intimidation and
harassment behaviour are subjective. Qualitative research by Musselman
et al. [28]
reveals an ambiguity that, while surgical trainees acknowledge the
existence of the negative effects of a bullying culture and “bad
intimidation” being part of surgical training, some trainees also
justify its occurrence and see “good intimidation” as an effective
educational tool. If the intent is for the trainee to improve their
performance and to ultimately have a positive effect on patient safety
and care then it may be arguably acceptable. Certainly if the intent is
to humiliate for negative purposes than this is unacceptable.
There is clear evidence that learning is more effective when fear and conflict is removed from the training environment
[34]
and although some bullying behaviours may be motivated by a desire to
improve performance, the impact is often to the contrary. Persistent
destructive criticism in front of colleagues will cause all but the most
resilient of surgical trainees to lose confidence. A humiliated and
undermined surgical trainee is less likely to seek help from a senior
when required or raise a concern when a mistake from a senior surgeon is
noticed.
Surgical
educators need to be properly trained and equipped with the personal
attributes required to be an effective trainer. Undermining and bullying
of trainees can occur when surgeons are tasked with the responsibility
of training despite not having the tools to cope with it. Service
pressures can also compromise effective support, training and
supervision of surgical trainees. The GMC has recognised that formal
recognition and approval of trainers in secondary care is long overdue,
with recognition to be a prerequisite for surgical trainers acting as
named educational or clinical supervisors by July 2016
[35]. The RCSEd Faculty of Surgical Trainers (FST) has proposed seven standards for surgical trainers
[36], based on the Academy of Medical Educators (AoME) “
Framework for Supervisors”
[37] which requires surgical trainers to provide evidence that they meet standards. Of note, “
Establishing and maintaining an environment for learning” and “
Guiding personal and professional development”
are two of the standards that especially promote positive attitudes and
behaviours towards trainees. The process of recognition and approval of
surgical trainers will prevent those consultant surgeons who do not
have the required attributes and skills to be an effective trainer from
having the privilege of supervising surgeons in training in the future.
6. Tackling undermining and bullying of surgical trainees
6.1. Current processes and how to raise concerns regarding undermining and bullying
For
individual trainees who experience being undermined or bullied at work
there are various options that can help manage the problem. There is
often no quick fix or “one size fits all” option, so approaches need to
be individualised
[38].
Formal guidance can be obtained by consulting local Trust policy on
bullying and harassment which is generally available from the Trust's
human resources department. Advice can also be obtained from a local BMA
representative or by consulting the BMA website
[39]. Help and counselling should also be available from local occupational health services.
Sometimes
perceived undermining and bullying is not deliberate or may be an
isolated event. Proportionate actions should therefore be taken and
ideally trainees who have concerns regarding undermining and bullying
should speak with an appropriate senior colleague to obtain confidential
and non-judgemental support and advice before making a formal
complaint. This could be an educational or clinical supervisor, college
tutor, clinical director or training programme director. Where
appropriate, Trusts and deaneries may then undertake their own internal
investigation or rarely may invite an external body, such as the GMC or
the Royal College of Surgeons of England (RCSEng), via its Invited
Review Mechanism (IRM) to help identify and mediate issues.
The
annual training survey by the GMC is a good opportunity to raise
anonymous concerns regarding undermining and bullying. However, the
survey is only open for a six-week period each year. The Joint Committee
on Surgical Training (JCST) survey, which is to be completed by each
trainee after every placement, is another opportunity to raise concerns
regarding undermining and bullying, however responses are not anonymous.
Although responses are not identifiable by individual's name, they are
identifiable by GMC number, speciality and hospital. For trainees who
feel unable to raise concerns at a local level within the Trust or to
the deanery, then contacting the GMC directly via the GMC helpline is a
further option.
Depending
on the nature of concerns raised, the GMC may then decide to conduct a
quality assurance visit of relevant surgical departments. Concerns
regarding undermining and bullying identified by the GMC are shared with
deaneries, LETBs and Royal Colleges. Likewise this may trigger a visit
to the unit from the deanery and LETB who will then report back to the
GMC. If problems cannot be resolved by the deanery then the GMC may be
called upon to oversee a period of enhanced monitoring which involves
publishing details, including naming the unit and providing a summary of
the concerns on the GMC website. Training posts may be withdrawn from
units where undermining and bullying remains unresolved.
7. ASiT recommendations
The
vast majority of UK surgical trainees are working in positive training
environments. However there remains a need for action to eliminate
undermining and bullying in surgical training whilst promoting positive
workforce behaviour amongst surgical teams and creating supportive
training units. Despite the current processes in place at national,
regional and local levels, surgical trainees are still being undermined
and even bullied at work with many trainees still not able to raise such
concerns. ASiT therefore makes the following recommendations, aimed at
both organisational and surgical departmental levels:
Recommendations at organisational level:
- •
A
long-term strategic commitment from over-arching institutions,
including the GMC, the four surgical Royal Colleges and the JCST, is
required to address undermining and bullying of surgical trainees by
promoting formal policies and procedures, undertaking proactive
monitoring of data to identify outliers and individual surgical units
where undermining and bullying is an issue, and to provide targeted
interventions to these units.
- •
Deaneries
and LETBs should be alert for signs of undermining and bullying and
should acknowledge and take ownership of any issues that arise.
- •
The
profile of undermining and bullying should be raised within the
surgical specialities by inclusion in Trust and Deanery training scheme
induction processes.
- •
Systems should be in place to allow bullying or undermining to be reported without fear of recrimination.
- •
A
duty should be placed upon Trusts to report incidents of undermining or
bullying to the relevant training committee for further investigation.
- •
Deanery
mechanisms should be in place for the removal of trainees from
placements which are consistently shown to present an unsuitable
environment in terms of bullying or undermining, regardless of the
eminence or previous track record of the department and individuals
therein.
- •
Deaneries
should take responsibility for the timely investigation of potential
undermining and bullying, as it is within their remit to ensure
appropriate training placements.
- •
Once
concerns have been investigated and proven to have foundation, referral
to the appropriate regulatory body for a disciplinary investigation
should be routine.
- •
Trainees
should not be placed within a department that is under investigation,
or one with a proven record of undermining or bullying until robust
processes have been followed to ensure this will not continue or recur
and individuals or departments have undergone a period of retraining.
- •
ASiT strongly support the formal recognition and approval of surgical trainers
[35] against published standards
[36] in order to enhance the value and visibility of the surgical trainer's role.
- •
A
national surgical mentorship scheme for trainees should be developed
with the surgical Royal Colleges through the LETBs. In addition to
benefits on career progression and advice, mentoring provides a safe
environment in which to constructively share concerns whilst improving
working relationships with colleagues
[40].
Recommendations at departmental level required to create a positive and supportive training environment:
- •
Effective
senior leadership within cohesive surgical departments with flattened
hierarchies that provide platforms for excellent training.
- •
Appropriate time and resources for training need to be provided within a suitable model of service delivery.
- •
Effective
communication with surgical trainees with processes put into place,
such as trainee forums, in order to recognise undermining and bullying
and facilitate reporting without fear or recrimination.
- •
Ensure
that consultant surgeons within the surgical department who supervise
trainees gain formal recognition and approval of their status as a
surgical trainer
[35] and
[36].
8. Conclusion
The
vast majority of UK surgical trainees are working in positive and
supportive training environments. However, undermining and bullying
remains widespread within medicine and occurs at a proportionately
higher rate within surgical specialities. Undermining and bullying have
serious consequences for the recipient of such behaviours, and can
result in poor treatment of patients as well as adverse consequences for
the individual involved. Objective evidence that concerns about
undermining and bullying are recognised, investigated, and acted upon
should be apparent at Trust, Deanery and GMC levels. Undermining and
bullying has no place in modern surgical training and those perpetuating
the model of ‘learning by humiliation’ should not be permitted to do
so. It should be expected that there will be professional consequences
to both the perpetrator and the organisation involved when bullying or
undermining is found to be present and unaddressed. ASiT will continue
to work alongside other trainee groups and professional bodies to raise
the profile of undermining and bullying and to demonstrate the need for
ongoing monitoring and action against such events and behaviours.
Funding
Nil.
