International Journal of Surgery
Volume 23, Supplement 1, November 2015, Pages S5–S9
ASiT 2015 Conference Poster Abstracts
Editorial


doi:10.1016/j.ijsu.2015.09.017
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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.

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