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Abstract
We set ourselves very high standards at work and when there is a sense that somehow we have failed, we are left feeling disappointed and frustrated. We all set very high standards for ourselves. When those feelings are exacerbated by the embarrassment of a public dressing down, especially if there isn’t an opportunity to explain just how difficult the situation had been, we are left feeling angry and let down. Most of us learn how a bully behaves in the playground or at nursery school—and yet, when it happens as an adult at work we often fail to realise what is happening. Harassment or undermining behaviour can be more challenging to identify because it isn’t always obvious and can happen without colleagues being aware. Sometimes, it isn’t even apparent to those who experience it, until an event means the problem becomes overwhelming. In fact, many people who experience undermining at work perceive the problem as their own and this can have a far more insidious impact on well-being, professional performance and mental health.
- medical education
- paediatric practice
- paediatric staffing
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‘Carrie is finishing a busy night shift and handing over to the day team. She presents the case of a baby admitted at 3am with suspected sepsis. The baby was started on intravenous antibiotics before a urine sample could be collected from the baby. The consultant for the day is very dismissive of this management plan, commenting in front of the whole team that it is ‘much better scientifically’ to collect all the samples for culture before starting antibiotics. Carrie feels devastated. The night shift had been awful as they were one doctor short due to illness. She feels her hard work is unrecognised and now her decision-making has been criticised.’
Carrie had an experience many of us can relate to. Her reaction is how most respond. We set ourselves very high standards at work and when there is a sense that somehow we have failed, we are left feeling disappointed and frustrated. We all set very high standards for ourselves. When those feelings are exacerbated by the embarrassment of a public dressing down, especially if there isn’t an opportunity to explain just how difficult the situation had been, we are left feeling angry and let down. Most of us learn how a bully behaves in the playground or at nursery school—and yet, when it happens as an adult at work we often fail to realise what is happening. Harassment or undermining behaviour can be more challenging to identify because it isn’t always obvious and can happen without colleagues being aware. Sometimes, it isn’t even apparent to those who experience it, until an event means the problem becomes overwhelming. In fact, many people who experience undermining at work perceive the problem as their own and this can have a far more insidious impact on well-being, professional performance and mental health (box 1).
Definitions of bullying, harassment and undermining13
Bullying: Bullying is behaviour that hurts or frightens someone who is less powerful, often forcing them to do something they do not want to do. It typically involves a raised voice, humiliation in front of colleagues, or issuing of threats for example, ‘If you don’t do that night shift I’m going to make sure you don’t pass your appraisal’.
Undermining: ‘behaviour that subverts, weakens or wears away confidence’ for example, ‘better not ask you to do that job, you’d probably cry’.
Harassment: defined under the 2010 Equality Act as ‘unwanted conduct related to a relevant protected characteristic which has the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual’.14
The National Health Service Staff Survey documents the rates of bullying, harassment and abuse experienced by staff each year. Over time, this has demonstrated an incremental rise in this problem. In 2018, almost one in five healthcare workers reported being bullied or undermined by a colleague—a rise of 1% since 2017.1 Among doctors, the incidence is similar and this is more than three times higher than in the wider workforce, according to BMA (British Medical Association) data.2 The Royal College of Obstetrics and Gynaecology shone a light on their own specialty with a study that found more than 40% of consultants reporting persistent bullying or harassment.3 Other specialities have also developed campaigns to challenge undermining behaviour and bullying in the workplace. Orthopaedic surgeons in the UK have led the way with their #hammeritout campaign, identifying what unacceptable behaviour looks like, and the importance of challenging it (see box 2).
Words from the front line: developing the British Orthopaedic Trainees’ Association #hammeritout campaign.
Simon Fleming orthopaedic registrar and past president of the British Orthopaedic Trainees’ Association (BOTA) started the #hammeritout campaign. He has been hugely influential in starting important conversations about bullying within orthopaedics. In a recent blog15 he wrote
‘I had the lived experience of me, my committee and my membership, which told me that the NHS had a problem. When, at the beginning of my “anti-bullying” journey, I reflected on nearly all the issues I was confronted with, in orthopaedics, in surgery, in the NHS, and in healthcare, the answer that kept coming up was “culture”. When you ask a medical student about which rotations they have enjoyed the most, or where they don’t want to go, their answers will cover a few themes, but culture always lies at the heart of it. When you look at why junior doctors leave after FY2 (second year of working as a doctor) or don’t enter some specialties, the answer is culture.
The answer, therefore, to me, appeared abundantly clear. Not just as BOTA President, nor as a trainee, but simply as a person with a voice and the drive to speak for those who didn’t feel they could. For those who couldn’t see there was problem and simply needed it pointing out to them. To all those who wanted to make things better, for staff and for patients alike…there really was an obvious answer. To start a campaign to get people talking, make people aware of the cultural issues within the NHS, especially around bullying, undermining behaviour, and harassment.’
Paediatrics has some unique challenges as a specialty. The mantra is often that paediatricians are people who like teamwork, prefer a flat hierarchy and are approachable and friendly—after all, we work with children! This may all be true, but this makes recognising and then challenging bullying and undermining behaviour in paediatrics very difficult. As a result, those who experience it often keep quiet and can be made to feel that the problem is theirs, not the challenging and hostile working environment.
Workplace culture has been studied across many professions, and in many different environments and organisations. The message that underpins all the work in this area is that rudeness and incivility at work is highly destructive for both teams and individuals. Even minor acts of thoughtlessness can erode engagement, morale and lead to alarmingly high levels of lost time at work, reduction in performance, increased rudeness to customers (patients) and loss of organisational commitment.4 In healthcare, there is a well-described link between staff who feel unfairly treated or disempowered, poor performance and therefore worse patient outcomes.5
There is a paucity of data around negative workplace culture in Paediatrics. In a recent study surveying nearly 400 neonatal intensive care unit doctors and nurses using a validated inventory for workplace bullying, over half reported experiencing bullying behaviours at work.6 Another study randomised participants to one of two simulation scenarios, based around a deteriorating preterm baby with necrotising enterocolitis. The study very elegantly showed that rudeness harmed the ability of team members to accurately diagnose a problem and undertake practical procedures. Additionally, rude behaviour adversely affected the collaborative ways in which the team worked when things went wrong. This impaired their ability to compensate for setbacks and had a direct clinical impact.7 The impact of such behaviour in a hospital paediatric setting or community paediatric settings is much less well studied.
The significance and extent of bullying and undermining in Paediatrics in the UK was brought into focus by a ‘Twitter’ conversation in early 2019, which led to a workshop at the Royal College of Paediatrics and Child Health (RCPCH) annual conference in May 2019. The intention of the workshop was to explore how rude, undermining and bullying behaviour presents to paediatricians of all grades and led to a lively discussion and defined the need to address the issue of workplace culture more proactively (box 3). This was therefore taken up by the RCPCH Trainees’ Committee where a mandate to lead this work was confirmed. The Committee supported the commitment to undertake this work and particularly wanted to shine a light on the insidious nature of bullying and undermining in Paediatrics.
Questions posed to workshop participants at RCPCH conference
Have you been bullied—by whom? What grade are you?
How did bullying/undermining make you feel?
Solutions to combat it?
When does developmental feedback become undermining?
Focus group work with trainees has highlighted four professional scenarios in which rudeness and incivility is particularly likely to happen (box 4):
Focus group work with trainees highlighted four professional scenarios in which rudeness and incivility is particularly likely to happen:
1. Handover
The case of Carrie at the beginning of the paper illustrates how conversations over handover can often be challenging. While it can be tempting to look at the wider learning for all trainees we must be mindful of the individuals involved. Feedback that isn’t expected can be challenging to receive—see below. Ground rules for handover are important and a single person leading the session is key.
2. Educational supervision and feedback
Receiving feedback can be difficult. We all set very high standards for ourselves. However we all need to think about how we receive feedback so we can be open to challenge in a supportive way. It is the balance of challenge and support we need to ensure. Feedback aimed at personal attributes or personality, rather than situation can be seen as undermining and harder to change. Feedback that is challenging and will evoke emotions needs to be handled carefully and sensitively with support. When this is conducted in a public it can be undermining for those involved and challenging for those who witness it. Feedback that is likely to be difficult to receive should always be done in person and in a private setting. It should not be done ‘in the heat of the moment’ unless there is a true imperative. It is important to provide objective evidence and examples of behaviour—not just Chinese whispers and say-so. It is never acceptable to give damning feedback via a multisource feedback tool under cover of anonymity.
3. Language and communication
How we chose our words and the context in which they are delivered are so important. Passing comments which may be meant lightheartedly can be misconstrued very easily. In the world of social media there are additional ways in which bullying can happen, especially as it can be difficult to be nuanced in a post that has a word restriction. It is essential to be professional when you using social media and to avoid making sweeping generalisations. Within paediatrics, there can be social media storms after an ill-judged comment about less than full-time working or mental health difficulties.
4. Equality and diversity
There is plenty of evidence from a variety of sources that certain groups of doctors are more vulnerable to workplace bullying and harassment. In the National Health Service (NHS) Staff Survey1 disabled staff were the most likely to be bullied, followed by LGBT+ (lesbian, gay, bisexual, transexual)staff, BAME (black, asian and minority ethnic) staff and then women. Everyone needs to be sensitive to this, and clinical leaders need to particularly bear this in mind. The protected characteristics of colleagues are not always immediately apparent and again, throwaway comments may cause more offence than expected. A good principle is to ask people about themselves, any adjustments they require and how they refer to themselves rather than assuming you know.
Handover
Educational supervision and feedback
Language and communication
Equality and diversity
Paediatricians work in highly complex and constantly changing environments where the opportunities for conflict, undermining behaviour and rudeness are enormous. Sometimes this can happen when senior staff are themselves exhausted or under overwhelming pressure. Unwittingly, they may come across in a heavy-handed way or even be perceived as being bullying. Creating an opportunity to take that person aside to describe how their behaviour comes across is not just important, it is the essence of good teamwork. Each of us, under enough pressure, has the ability to behave in a way we may not be proud of (a ‘mean moment’)—but at least let’s politely call this out. The person involved may have something entirely unrelated to work going on that means they are stressed or under pressure.
Leadership is key here. Poor workplace culture will never change while clinical leaders and managers turn a blind eye—or even worse, actively undermine trust and fail to prevent the creation of toxic work environments. Great leaders treat their colleagues as individuals and promote teamwork and collaboration. They display compassion and actively work on relationship building—‘You don’t change culture through emails and memos. You change it through relationships …… One conversation at a time’.8 Compassionate leadership creates workplaces where people feel safe and connected, and so can focus on performing to the best of their ability. This was very comprehensively described in Google’s Project Aristotle, a study undertaken to try and understand what the key to a successful Google team was. Over 250 attributes were examined and more than 180 of their teams studied. The most important team dynamic by a long margin was ‘psychological safety’ that is, we can take risks without feeling insecure or embarrassed. Google teams, who reported high levels of psychological safety, were far more likely to admit their mistakes, take on new roles, stay in the organisation and be rated as effective by their seniors.9
Compassion from leaders and among teams can be promoted by encouraging simple behaviours at work. For instance, agree on a set of ground rules that everyone buys into such as starting handover on time, turning off phones in meetings, actively seeking feedback, and specifically showing appreciation. In addition, if a member of staff decides to leave, take the time to find out why—and conversely, when people stay in the organisation for a long time, stop and understand the reasons.
The world of sport provides us with some of the most visible examples of successful and productive ways of teamworking. Watching a winning team congratulating each other and collectively celebrating success is almost infectious! Teams flourish when members are clear about their individual responsibilities but the value of the team as a whole is paramount. Establishing a zero tolerance for rudeness and incivility at work must be absolute and no team member, no matter how talented or successful, can expect the rules to be different for them. Arguably the most successful rugby team on earth, the All Blacks, has a policy of ‘no dickheads’ and many believe this is at the root of their success. All Blacks mental skills coach Gilbert Enoka introduced the idea and he has instilled into the team the idea that success means putting the team first. This creates a sense of belonging within the team, and no individual is more important than the team. Even if you aren’t a rugby enthusiast, the logic is inescapable and for our specialty to flourish and continue to attract the best doctors and nurses, we need to stop and take stock, and reinvest in our teams to create positive and flourishing workplaces.
A ‘cup of coffee’ conversation can be a powerful way to discuss a single unprofessional incident. This is a way of naming the behaviour witnessed and challenging it, based on research from the Vanderbilt University School of Medicine in Tennessee. The GMC (General Medical Council) is piloting a training scheme10 to help doctors call out colleagues’ unprofessional behaviour using this framework. The importance of these conversations should build on Brené Brown’s work.11 ‘Clear is kind, unclear is unkind’ ensures we have brave conversations, that don’t sugarcoat the more challenging aspects of feedback but allow a conversation about it in an open way. We need to listen to understand (not to interrupt or argue) so that the conversation enables both parties to develop a shared understanding of the wider situation.
Finally, there is some emerging evidence that gratitude can improve medical team performance.12 Building team culture should also focus on being courteous to all, and that includes remembering to say ‘thank you’ more. Gratitude acknowledges a team member’s work and contribution and confirms the value of their role. This helps build a positive culture of development and improvement.
Conclusion
This article has sought to explore how rude, undermining and bullying behaviour affects our work in paediatrics. It is clear that these issues are widespread across healthcare and we must be honest with ourselves as a specialty about the extent of the problem in paediatrics. Our hope is that by focusing on the four areas of handover, feedback, communication, and equality and diversity we can begin to affect change in the teams in which we work. This is important. For the first time we are facing challenges in recruitment and retention of paediatricians. We must start to address key factors that affect colleague well-being and burn-out. It is win, win. If we look at how we work in our teams and start to have braver conversations we enhance the sense of team, improve well-being, and reduce bullying and undermining conversations. This more open culture enables us to provide higher quality care that is safe and compassionate. Let us all ‘be brave enough to start a conversation that matters’. (Margaret Wheatley)
Footnotes
Twitter @HannahCJacob, @anna_annabav, @CamillaKingdon
Contributors All authors co-wrote and developed the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.