Medical Ethics Group Project

The Impact of Workplace Bullying in Healthcare

Lily Jacobs, Heba Fakir, Amanda Rogers

Nia Grant, Shaindel Pinsky

Course: Biomedical Ethics

Instructor: Professor McGarry

July 15th, 2022

The AMA defines workplace bullying as “repeated emotionally or physically abusive, disrespectful, disruptive, inappropriate, insulting, intimidating, and/or threatening behavior targeted at a specific individual or group of individuals that manifests from a real or perceived power imbalance and is often, but not always, intended to control, embarrass, undermine, threaten, or otherwise harm the target” (Carlasare et al., 2021). The two main categories of bullying include overt and covert behaviors. Overt bullying includes “extreme micromanaging, verbal criticism, name-calling, insults, and direct threats” (Edmonson et al., 2019). This type of bullying is easily recognizable, yet still continues due to organizational dysfunction and poor management or lack thereof. Covert bullying is considered “passive aggressive” and includes actions such as rumors and gossip, anonymous cyberbullying and other microaggressions. 

When team members are subjected to this type of disrespectful behavior, especially if it is continual, it can result in absenteeism, depression/anxiety, burnout, isolation, suicidal thoughts, and may even cause disease conditions such as fibromyalgia or cardiovascular disease. It can completely destroy a safe workplace and create an unhealthy team dynamic. Members will be less likely to express their patient care concerns or ask for help due to fear of not being taken seriously or being bullied again. As a result, poor patient satisfaction rates, an increase in medical errors, and an increase in preventable adverse outcomes may occur. Therefore, it is crucial for team members to report incidents and for organizations to provide sufficient resources to address such issues. Everyone is responsible and everyone should be equally held accountable. Even if people are not actively participating in the behavior, remaining silent breaks the trust, respect, equity, and support that is expected within a team. Commitment to providing a better work culture that is safe and respectable, will ultimately help create a high-functioning medical team, thus leading to better quality patient care. 

Medicine has a culture of hierarchy, which makes the workplaces more susceptible to bullying. It often occurs in high-stress settings with heavy workloads and low job autonomy. Among the groups most bullied are nurses and medical residents (Edmonson et al., 2019). Nurse bullying has now become commonplace. Studies have shown that it can start as early as in nursing school, only to continue into clinical rotations, and then finally into one’s job. The article “Our Own Worst Enemies- The Nurse Bullying Epidemic” by Edmonson, et al. addresses these issues and states that 60% of nurses leave their first job in the first 6 months due to the bullying behavior of their coworkers, which are in fact mostly other nurses. The bullies range across the nursing workforce spectrum and are not limited to gender, age, or experience level. Older nurses bully the younger nurses on their lack of expertise, the younger nurses bully the older nurses on physical limitations, male nurses bully female nurses and vice versa, and nurses with a higher level of education bully those who have a lower degree or certification. In fact, even nurses in managerial roles may emulate the same leadership style of fear and intimidation as their bosses did with them, thus precipitating a never ending toxic cycle.

Similar to nurse bullying, the prevalence of bullying among medical students and residents is a cycle of abuse that starts from the very first day and continues through and after residency. This cycle is an ongoing loop and often starts again with the residents who were once bullied, reciprocating such behavior when they become attendings. In recent years, the media and various literature has revealed an alarmingly high rate of bullying among medical students, most commonly by the hands of physicians and surgeons. A presumption exists that one must be tough to have a job in medicine, however this presumption fuels an environment of mistreatment and bullying because it is often used to defend and justify the mistreatment of medical students. In 1990, a landmark study was published in the Journal of the American Medical Association (JAMA) which addressed the incidence, severity, and significance of abuse in medical students. The study found that 56.4% of the 519 participants reported being mistreated during some point in medical school and 49.6% of the participants that reported abuse claimed that the most serious abuse will always negatively affect them in some way. 

More recently, a 2006 study was published looking at the ongoing mistreatment among medical students. Out of the 2316 participants from 16 different U.S. medical schools, 85% of students reported being harassed or belittled, 13% of which described an incident that they would categorize as “severe.” Along with many other studies, they all share a common theme, a strikingly high rate (at least 50%) of bullying and harassment among medical students. One study in Sydney evaluated ten current or recently graduated medical students using semi-structured, in-depth interviews regarding their experiences of bullying in clinical settings. Six themes were identified amongst the interview transcripts that provide some insight into how medical students perceive the medical field, the most common one being hierarchy. All ten of the participants identified that a “hierarchy” exists in the workplace and that abuse of this hierarchy is what leads to bullying and a toxic workplace. This study revealed another issue, the lack of reporting mistreatment and bullying. Participants attributed their feelings of being unable to report incidents of bullying to the hierarchy and fear of any rebound effect, stating that senior physicians were unapproachable because they were “self-important, sexist, uninterested, too busy, or participants feared verbal abuse” (Colenbrander et al., 2020). Five participants stated that if they did experience bullying they would not report it because they do not believe any action would be taken. Additional barriers to reporting bullying included a lack of knowledge about available resources, lack of assurance of confidentiality, and a fear of impact on career. The mistreatment and bullying of medical students has long-lasting physical and mental consequences for future physicians that have the ability to affect future patient care. And still, workplace bullying within the medical student population is a very prevalent, yet underrepresented issue in the current day. 

With the alarming number of reports surrounding workplace incivility and bullying amongst healthcare workers, there have been lots of efforts to limit its presence within the medical community. According to an article published in Acta Biomedica regarding nurse bullying, it states that many facilities have institutionalized preventative and proactive practices such as increasing the awareness of workplace bullying amongst hospital staff, providing nurses with conflict management skills, implementing a zero tolerance strategy to abuse, and expressing healthcare workers conduct codes (Bambi et al., 2017). A systematic literature review of seven publications was conducted to analyze the efficacy of these preventive measures by measuring three different outcomes: nurses’ turnover, rate of bullying, and direct confrontation between target and perpetrator. After careful analysis, researchers concluded that just a single application of these measures to completely combat bullying amongst nurses and other hospital staff was ineffective. 

Recently, there has been an increased need to add innovative and “creative” solutions to address the problem–one of those surrounding the concept of emotional intelligence. The article written by Bambi et.al, (2017) explains that a deeper understanding of the four components of emotional intelligence is a starting point to mitigating stressors and managing emerging conflicts. Some authors propose focusing on a “Peace and Power” strategy, which is founded upon the ideas of “reflection and action” and “building a sense of community” in an attempt to make the perpetrators more aware of their words and actions. Furthermore, solutions of workplace bullying should involve organizational leadership, with measures put in place to detect its presence early on. The article states that the starting point to detection includes analyzing “absenteeism rates and group cohesion rates” as well as “performing general surveys on work environment climate.” A journal article published on Nurse Outlook proposes an implementation incentive strategy for institutions, including a method of factoring the level of nurse bullying into the calculation of value-based incentive payment (Castronovo et al., 2015). 

Education is another way in which workplace bullying can be addressed. One of the issues with workplace bullying is the incognizance of what qualifies as healthcare bullying, how to report it, and how to address it. In the article by Leisy et al. (2016), it was noted that after reviewing studies on resident knowledge, only half of the residents were aware of the reporting process regarding healthcare bullying. Healthcare workers and students, often, see harassment and intimidation as a “functional educational tool” ​​(Leisy et al., 2016). Pimping is a prime example of this–initially and for a long time it was seen as a reasonable method in teaching. However, pimping is now under scrutiny as a form of mistreatment through humiliation. It’s important that residents, medical students, nursing students, and PA students be aware of resources available for addressing lateral violence. Suggestions and guidelines can be found in “Procedures for Addressing Complaints and Concerns against Residency/ Fellowship Programs and Sponsoring Institutions,” “Institutional Requirements for Resident/ Fellow Learning and Working Environment, ” and “Distinguishing Between Concerns and Formal Complaints” from the Accreditation Council for Graduate Medical Education (Leisy et al., 2016).

Leadership is also another key and crucial factor in defining a just and safe culture in an organization. Supervisors can encourage collegiality and supportive relationships which can lessen stress and increase worker retention; hence the importance of placing supportive, impartial, and available physicians in supervising roles. Whereas, having an unsupportive or inadequate physician supervision can allow mistreatment to continue to occur in our medical training system without opposition. Creating a supportive system that can prevent workplace bullying through mentoring physicians-in-training may also be effective. A mentorship relationship can provide support for residents, nursing students, and PA students and also reduce harassment and belittlement rates during medical training ​​(Leisy et al., 2016). 

Institutions can benefit from having a bullying and mediation committee. Many hospital policies address illegal harassment and discrimination, but not gray areas like bullying and intimidation. The bullying and mediation committee approaches every mistreatment case as a manageable problem, along with having a zero tolerance system for combating bullying by: educating all team members on professional behavior, code of conduct, the process of disciplinary action, the detrimental effects of bullying, and creating systems for monitoring any unprofessional behavior. The committee must review and mediate any of these situations, create a definitive protocol for reporting workplace bullying/mistreatment along with an anonymous reporting system (that will alleviate the fear of retaliation), and determine penalties following the mistreatment. 

Lastly, there should be a focus on creating a culture that emphasizes patient safety, models professionalism, enhances collaborative behavior, encourages transparency, values the individual leader, eliminates hierarchical authority, and has zero tolerance for abusive/demeaning behavior. It was suggested that emphasizing interdisciplinary team based care during training can combat workplace bullying, since a team based mentality can lessen the hierarchical nature in medicine. As advised by a medical resident on how to prevent bullying, healthcare workers should “keep in mind that patient safety is our number one priority” and to keep our ego at the door while respecting each team member for their skills ​​(Leisy et al., 2016).

In conclusion, bullying in the workplace is detrimental to the work environment, and as a result of that, patient care. Nurses and medical students are just two examples of populations within the medical field who may experience bullying, however all healthcare providers may be subject to this at some point in their careers. As future physician assistants and healthcare workers, it is important to bring these issues to light, help mitigate these situations and advocate on the behalf of ourselves and our colleagues.  Though some studies may have shown lack of effectiveness in single implementations to control workplace bullying, multi-policy implementations with focus on emotional intelligence and team building can be beneficial. Additionally, promoting an attitude of inclusiveness, teamwork and collaboration amongst healthcare teams can ultimately establish cohesiveness and minimize conflict. Other ways to combat the situation include, education on how to identify and report lateral violence in the workplace, developing a bullying and mediation committee, and electing supportive healthcare mentors for students. Although there may still be some time before seeing the effects of these potential implementations, we can all agree on the seriousness and magnitude of this issue as one that warrants continued conversation and prompt intervention.

Works Cited

Bambi S, Guazzini A, De Felippis C, Lucchini A, Rasero L. Preventing workplace incivility, lateral violence and bullying between nurses: A narrative literature review. Acta Biomed. 2017 Nov 30;88(5S):39-47. doi: 10.23750/abm.v88i5-S.6838. PMID: 29189704; PMCID: PMC6357576.

Carlasare, L. E., & Hickson, G. B. (2021, December). Whose Responsibility Is It to Address Bullying in Health Care? AMA Journal of Ethics Volume 23, Number 12: E931-936. Retrieved from  https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2021-11/cscm4-peer-2112_0.pdf 

Castronovo MA, Pullizzi A, Evans S. Nurse Bullying: A Review And A Proposed Solution. Nurs Outlook. 2016 May-Jun;64(3):208-14. doi: 10.1016/j.outlook.2015.11.008. Epub 2015 Nov 22. PMID: 26732552.

Colenbrander, L., Causer, L. & Haire, B. ‘If you can’t make it, you’re not tough enough to do medicine’: a qualitative study of Sydney-based medical students’ experiences of bullying and harassment in clinical settings. BMC Med Educ 20, 86 (2020). https://doi.org/10.1186/s12909-020-02001-y

Edmonson, Cole DNP, RN, FACHE, NEA-BC, FAAN; Zelonka, Caroline BS Our Own Worst Enemies, Nursing Administration Quarterly: July/September 2019 – Volume 43 – Issue 3 – p 274-279 doi: 10.1097/NAQ.0000000000000353

Leisy, H. B., & Ahmad, M. (2016). Altering workplace attitudes for resident education (A.W.A.R.E.): discovering solutions for medical resident bullying through literature review. BMC medical education, 16, 127. https://doi.org/10.1186/s12909-016-0639-8