Bullying has significant, far-reaching consequences for all health professionals, students, trainees, patients, their families, and organizations. Bullying is antithetical to healthy organizational culture, patient safety, and professionalism. A culture of safety and respect in sites of health care education and work is foundational to the well-being of everyone in health care. This commentary on a case recommends individual and collective responses to bullying that express fundamental clinical and ethical values and what it means to be a professional.
Dr S is a second-year surgery resident who is apprehensive about a last-minute assignment to assist Dr T in an aortic valve replacement for the patient, JJ. Dr T often condescended to many students, trainees, and colleagues and repeatedly made public, belittling remarks about Dr S’s performance, specifically. During JJ’s surgery, Dr T ordered Dr S to get a 28 mm St Jude mechanical valve. Dr S paused, however, recalling from JJ’s patient record a prior episode of intestinal bleeding. Dr S wondered whether Dr T knew about this detail in JJ’s history, which would influence evaluation of prospective risks and benefits of long-term anticoagulation therapy that standardly follows mechanical valve placement. Dr S felt intimidated by Dr T and hesitated, wanting to ask whether a bioprosthetic valve, which would not necessitate anticoagulation therapy, might be more appropriate for use in JJ’s case.
Dr T shouted, “What are you waiting for, S? Get the valve or get out!” Members of the surgical team looked away, including Dr A, an anesthesiologist who has often witnessed Dr T’s outbursts and their effects. Dr S retrieved the valve and was distracted throughout the rest of the surgery. Hours later, Dr S reminded herself to make sure there was a plan for evaluating the patient’s need for long-term anticoagulation.
Professionalism is the conduct, values, and qualities that characterize members of a profession and guide decision making in ethically challenging, rapidly changing clinical practice environments.1 Health professionals have duties to maintain competency and skill standards in their fields, practice self- and group-regulation,2 and express enduring commitment to reliable, safe, equitable care for all patients. Clinicians also commit to practice with empathy, compassion, respect, collegial engagement, and teamwork. High-functioning teams demonstrate defining characteristics of professionalism: sharing core ethical values, modeling respect for fellow professionals, and promoting cultures in which everyone feels safe asking questions.3 When well-functioning professional teams are partnered with health systems with shared goals and values—and when leaders are committed to building systems that make it easy for team members to do the right thing—a culture of safety is possible.
Safety Culture Undermined
The American Medical Association (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 a 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.”4 Bullying can affect anyone regardless of gender,5 occupational status,6 or nationality7 and is more frequently reported by women7,8 and members of some racial and ethnic groups.9,10
Disrespectful behavior, including bullying and aggression, directed toward colleagues and learners diminishes their vigilance and willingness to share concerns or ask for help and threatens team performance.11,12 Disrespectful behavior contributes to errors, patient dissatisfaction, and preventable adverse outcomes.12,13,14,15,16 Patients who receive care from surgeons like Dr T are more likely to experience complications (eg, surgical site infections, cardiac arrest, septic shock, and stroke).16,17
When single incidents go unaddressed over time, they forge dysfunctional practice patterns.
Team members subjected to behavior like Dr T’s report diminished professional satisfaction, isolation, burnout, distress, depression, anxiety, and suicidal ideation.18,19,20,21,22 Those regularly exposed or subject to patterns of disrespect can experience pain, fibromyalgia, and cardiovascular disease.23,24,25,26,27 Bullying contributes to increased absenteeism19,28 and can undermine organizations’ attempts to build respectful, safe workplaces.13,29 Reputational damage, legal costs, and turnover are other organizational consequences of bullying and disrespectful behavior.30,31,32 When single incidents go unaddressed over time, they forge dysfunctional practice patterns.33 As a seasoned observer of Dr T’s abusive behavior, Dr A, for example, also regularly lets colleagues down by remaining silent, further eroding trust, undermining effective communication, and threatening patient safety.11,13,18,28,29,34,35,36
Everyone Is Responsible
When team members model courage by speaking up in the moment and reporting incidents when needed, they reinforce desirable, safety-oriented clinical and ethical values (eg, respect, equity, inclusion) and help strengthen organizational cultures of safety. As health care practice continues to evolve and care delivery trends change, addressing disrespect and bullying will require collaboration among clinicians, professional societies, health professions schools and their admissions committees, and health care organizational leaders. Preventing bullying begins with recognizing the need to promote self-reflection and self-regulation opportunities during professional development, before patterns of dysfunctional, unprofessional behavior emerge. To help organizations achieve a workplace safety culture, the AMA established guidelines, among which the following are key4:
- Describe organizational leaders’ “commitment to providing a safe and healthy workplace.”
- “Outline steps for individuals to take when they feel they are a victim of workplace bullying.”
- “Provide contact information for a confidential means for documenting and reporting incidents.”
- Establish “procedures and conduct interventions within the context of the organizational commitment to the health and well-being of all staff.”
Establishing and maintaining a system-wide peer reporting and feedback mechanism improves accountability and enhances professional self-regulatory capacity and can help motivate self-reflection.33 For example, professionals should consider the following questions:
- Do I understand relationships between disrespect and adverse outcomes for my patients?
- What should I do to make it easier for others to collaborate with me to care well for our patients?
- Do I understand how to respond to someone expressing disrespect toward a colleague, patient, or myself?
- How should I partner with organizational leaders to support my colleagues effectively and sustainably?
Organizations have duties to patients and staff to promote safety, to promote awareness of threats to safety that bullying and other forms of disrespect create, to establish clear processes by which incidents that threaten safety can be safely reported (eg, by minimizing vulnerability to or fear of reprisal), and to review and respond to incidents and patterns of unprofessional behavior equitably and effectively. In our experience, responses to reports of incidents are not well coordinated or consistently or equitably applied to all team members, especially when abuse is committed by individuals like Dr T who, despite being viewed as “high value” in terms of having cultivated an exclusive skill set or capacity to generate revenue, enact behaviors corrosive to collegiality or the reputation of the organizational workplace.37,38,39,40
The pursuit of a high-functioning professional team begins with steadfast confirmation of shared clinical and ethical values expressed through professional collaboration with active organizational leaders with the courage and authority to offer consistent reinforcement of values and consistent messaging and enforcement (eg, in performance reviews) of behaviors and practices that are incentivized (or penalized). To promote a culture of safety and professionalism, leaders should hold everyone equally accountable, recognize professionals who exceed expectations, employ and effectively utilize reporting systems, and provide sufficient resources to individuals and teams to build and maintain these efforts.41 It is through this commitment to a better culture focused on safety that all health care workers and trainees, organizational leaders, administrators, patients, and families can stand up for medicine and be vigilant advocates for the medical profession.
- Egener BE, Mason DJ, McDonald WJ, et al. The Charter on Professionalism for Health Care Organizations. Acad Med. 2017;92(8):1091-1099.
Hickson GB, Moore IN, Pichert JW, Benegas M Jr. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line: Essential Issues for Health Care Leaders. 2nd ed. Joint Commission Resources; Institute for Healthcare Improvement; 2012:1-36.
Edmondson AC. Wicked-problem solvers. Harvard Business Review. June 2016. Accessed June 24, 2021. https://hbr.org/2016/06/wicked-problem-solvers
American Medical Association. Bullying in the practice of medicine H-515.951. Accessed October 9, 2021. https://policysearch.ama-assn.org/policyfinder/detail/AMA%20Policy%20H-515.951?uri=%2FAMADoc%2FHOD.xml-H-515.951.xml
- O’Donnell SM, MacIntosh JA. Gender and workplace bullying: men’s experiences of surviving bullying at work. Qual Health Res. 2016;26(3):351-366.
- Ortega A, Høgh A, Pejtersen JH, Feveile H, Olsen O. Prevalence of workplace bullying and risk groups: a representative population study. Int Arch Occup Environ Health. 2009;82(3):417-426.
- Salin D. Prevalence and forms of bullying among business professionals: a comparison of two different strategies for measuring bullying. Eur J Work Organ Psychol. 2001;10(4):425-441.
- Rouse LP, Gallagher-Garza S, Gebhard RE, Harrison SL, Wallace LS. Workplace bullying among family physicians: a gender focused study. J Womens Health (Larchmt). 2016;25(9):882-888.
- Lewis D, Gunn R. Workplace bullying in the public sector: understanding the racial dimension. Public Adm. 2007;85(3):641-665.
- Fox S, Stallworth LE. Racial/ethnic bullying: exploring links between bullying and racism in the US workplace. J Vocat Behav. 2005;66(3):438-456.
- Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136(3):487-495.
- Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Qual Saf. 2019;28(9):750-757.
Sentinel event alert 40: behaviors that undermine a culture of safety. Joint Commission. July 9, 2008. Updated June 2021. Accessed October 9, 2021. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-40-behaviors-that-undermine-a-culture-of-safety/
- Longo J, Hain D. Bullying: a hidden threat to patient safety. Nephrol Nurs J. 2014;41(2):193-200.
- Houck NM, Colbert AM. Patient safety and workplace bullying: an integrative review. J Nurs Care Qual. 2017;32(2):164-171.
- Cooper WO, Spain DA, Guillamondegui O, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surg. 2019;154(9):828-834.
- Cooper WO, Guillamondegui O, Hines OJ, et al. Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications. JAMA Surg. 2017;152(6):522-529.
- Sansone RA, Sansone LA. Workplace bullying: a tale of adverse consequences. Innov Clin Neurosci. 2015;12(1-2):32-37.
- Lever I, Dyball D, Greenberg N, Stevelink SAM. Health consequences of bullying in the healthcare workplace: a systematic review. J Adv Nurs. 2019;75(12):3195-3209.
- Ariza-Montes A, Muniz NM, Montero-Simó MJ, Araque-Padilla RA. Workplace bullying among healthcare workers. Int J Environ Res Public Health. 2013;10(8):3121-3139.
- Nielsen MB, Nielsen GH, Notelaers G, Einarsen S. Workplace bullying and suicidal ideation: a 3-wave longitudinal Norwegian study. Am J Public Health. 2015;105(11):e23-e28.
- Leach LS, Poyser C, Butterworth P. Workplace bullying and the association with suicidal ideation/thoughts and behaviour: a systematic review. Occup Environ Med. 2017;74(1):72-79.
- Kääria S, Laaksonen M, Rahkonen O, Lahelma E, Leino-Arjas P. Risk factors of chronic neck pain: a prospective study among middle-aged employees. Eur J Pain. 2012;16(6):911-920.
- Saastamoinen P, Laaksonen M, Leino-Arjas P, Lahelma E. Psychosocial risk factors of pain among employees. Eur J Pain. 2009;13(1):102-108.
- Kivimäki M, Leino-Arjas P, Virtanen M, et al. Work stress and incidence of newly diagnosed fibromyalgia: prospective cohort study. J Psychosom Res. 2004;57(5):417-422.
- Ayyala MS, Chaudhry S, Windish D, Dupras D, Reddy ST, Wright SM. Awareness of bullying in residency: results of a national survey of internal medicine program directors. J Grad Med Educ. 2018;10(2):209-213.
- Kivimäki M, Virtanen M, Vartia M, Elovainio M, Vahtera J, Keltikangas-Jarvinen L. Workplace bullying and the risk of cardiovascular disease and depression. Occup Environ Med. 2003;60(10):779-783.
- Kivimäki M, Elovainio M, Vahtera J. Workplace bullying and sickness absence in hospital staff. Occup Environ Med. 2000;57(10):656-660.
Quick safety 24: bullying has no place in health care. Joint Commission. Updated June 2021. Accessed October 9, 2021. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-24-bullying-has-no-place-in-health-care/bullying-has-no-place-in-health-care/
Fowler J. Financial impacts of workplace bullying. Investopedia. July 16, 2012. Accessed December 18, 2019. https://www.investopedia.com/financial-edge/0712/financial-impacts-of-workplace-bullying.aspx
- Hogh A, Hoel H, Carneiro IG. Bullying and employee turnover among healthcare workers: a three-wave prospective study. J Nurs Manag. 2011;19(6):742-751.
- Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951-2957.
- Webb LE, Dmochowski RR, Moore IN, et al. Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. Jt Comm J Qual Patient Saf. 2016;42(4):149-161.
- Ayyala MS, Rios R, Wright SM. Perceived bullying among internal medicine residents. JAMA. 2019;322(6):576-578.
- Wallace SC, Gipson K. Bullying in healthcare: a disruptive force linked to compromised patient safety. Pa Patient Saf Advis. 2017;14(2):64-70.
- Sprigg CA, Niven K, Dawson J, Farley S, Armitage CJ. Witnessing workplace bullying and employee well-being: a two-wave field study. J Occup Health Psychol. 2019;24(2):286-296.
Beta Heart®. Beta Healthcare Group. Accessed June 29, 2021. https://betahg.com/risk-management-and-safety/beta-heart/
Beta Heart—care for the caregiver. Beta Healthcare Group. Accessed June 29, 2021. https://betahg.com/beta-heart-care-for-the-caregiver/
- Pichert JW, Moore IN, Karrass J, et al. An intervention model that promotes accountability: peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013;39(10):435-446.
- Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82(11):1040-1048.
Hickson GB, Cooper WO. Pursuing professionalism (but not without an infrastructure). In: Byyny RL, Byyny R, Christensen S, Fish J, eds. Medical Professionalism Best Practices: Addressing Burnout in Our Profession. Alpha Omega Alpha Honor Medical Society; 2020:chap 7. Accessed October 9, 2021. https://www.alphaomegaalpha.org/wp-content/uploads/2021/10/2015MedicalProfessionalism.pdf