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Workplace Bullying and Harassment - 2009. Revised 2015

03 Dec 2015

Introduction

All doctors have the right to train and practice in a safe workplace free from bullying and harassment.[1][2][3] [4] However, the hierarchical nature of medicine, gender and cultural stereotypes, power imbalance inherent in medical training, and the competitive nature of practice and training has engendered a culture of bullying and harassment that has, over time, become pervasive and institutionalised in some areas of medicine.

The AMA believes the medical profession must take a leadership role in condemning bullying and harassment as and where it occurs. This position statement affirms the AMA’s commitment to a zero tolerance approach to all forms of bullying and harassment in the workplace. It should be read in conjunction with the AMA’s Position Statements on Sexual harassment in the medical workplace - 2015 and Equal Opportunity in the Medical Workforce - 2012.

1.     Definition and legal responsibilities

1.1.  Bullying is unreasonable and inappropriate behaviour that creates a risk to health and safety. It is behaviour that is repeated over time or occurs as part of a pattern of behaviour. Such behaviour intimidates, offends, degrades, insults or humiliates. It can include psychological, social, and physical bullying.4[5]

1.2.  Harassment is unwanted, unwelcome or uninvited behaviour that makes a person feel humiliated, intimidated or offended, Harassment can include racial hatred and vilification, be related to a disability, or the victimisation of a person who has made a complaint.4

1.3.  Employers have a duty of care under a range of laws to ensure the health, safety and welfare of their employees. This includes identifying bullying and harassment and taking steps to eliminate and prevent it. The legislation also requires employees to take reasonable care for their own health and safety as well as for the health and safety of others who may be affected by their acts in the workplace.

2.     Extent and impact of workplace bullying

2.1.  Medical students, doctors in training, female colleagues and international medical graduates have been identified as the most likely targets of bullying and harassment within the medical profession.[6] 3 Teaching by humiliation has been consistently reported by medical students3 and research suggests that up to 50 per cent of doctors, doctors in training and international medical graduates have been bullied or harassed.[7][8] [9]Verbal harassment is most commonly cited, and senior doctors are named as the most common source of harassment. Bullying can also occur between doctors in training with more senior trainees most likely to be reported as the perpetrator. Other factors which increase the risk of workplace bullying and harassment include the presence of work stressors, leadership styles, systems of work, work relationships and workforce characteristics. [10]

2.2.  Incidences of bullying and harassment are often not reported because of fear of reprisal, lack of confidence in the reporting process, fear of impact on career, and/or cultural minimisation of the problem. Hospitals and professional associations may unintentionally foster a culture of bullying as a result of failing to act or by discouraging change in preference to meeting service demands.6

2.3.  Workplace bullying contributes to poor employee health including the physical and psychological manifestations of stress and depression.  Others indirect costs include diminishing staff performance, reduced staff morale, reduced quality of patient care, and ultimately deteriorating patient safety. [11]

2.4.  Workplace bullying and harassment of medical students, doctors in training and doctors creates an unsafe and ineffectual work and learning environment due to the continued erosion of confidence, skills and initiative, and can create a negative attitude towards a chosen career. Victims of bullying report being less satisfied with their current jobs and with being doctors, are more affected by job stressors and are more likely to be considering ceasing direct patient care than non-bullied doctors.[12] Exposure to bullying and harassment presents a risk to the retention of medical practitioners in clinical practice and in doing so threatens community access to quality medical care.

AMA position

3.     Culture and Professionalism

3.1.  The medical profession must take direct responsibility for its culture, reputation and standard of professionalism. It must provide a professional, clinical and academic environment that exemplifies the values it wants doctors to embody and does not require doctors at any stage of their career to experience abuse.[13] [14]

3.2.  Medical colleges have a vital role to play in honouring the “societal contract” that exists between the profession and the public, in ensuring that bullying and harassment is not tolerated and in championing professionalism and standards.6

3.3.  Tackling the problem of bullying and harassment requires changing the culture within organisations. Bullying and harassment thrives in a workplace culture where it progresses unchallenged and is ignored. Practical and positive initiatives that can be implemented by medical colleges, other education providers and employers include:

3.3.1. Having a clear and well publicised policy in place to tackle bullying and harassment issues.

3.3.2. Establishing cultural improvement programs.

3.3.3. Fostering an environment where staff feel able to raise any concerns before they become problems.

3.3.4. Establishing good examples through positive role models.

3.3.5. Empowering bystanders to take action against bullying and harassment behaviours when they see it through education and by positively endorsing reporting

3.3.6. Having a recognised champion against bullying and harassment in each organisation/workplace.

3.3.7. Undertaking recurring surveys which focus on and monitor workplace culture.

3.4.  The accreditation standards for medical education and training should require medical colleges and other education providers to have policies, processes, education, training and support services in place to confront bullying and harassment within organisations and the workplace.

4.     Policy

4.1.  Employers, medical colleges and other medical education providers have an important role to play in raising the awareness of, and changing the culture of, bullying and harassment in the medical profession and health care sector. Well-thought-out and publicised policy in this area is important to foster a safe and healthy work and training environment, and maintaining appropriate standards of patient care.

4.2.  The AMA encourages medical colleges, other education providers and employers to develop and promote consistent anti-bullying and harassment policies. Such policy should include:

4.2.1. A commitment to eradicating workplace bullying and harassment.

4.2.2. A clear statement of zero tolerance in relation to bullying behaviours, irrespective of the role or seniority of the perpetrator.

4.2.3. Adoption of a visible, organisation-wide anti-bullying and harassment policy, which: 

  • Acknowledges that bullying and harassment is a problem.
  • Identifies examples of bullying behaviour.
  • Clearly outlines roles and responsibilities concerning bullying and harassment.
  • Outlines the steps that will be taken to prevent bullying and harassment.
  •  Provides tiered response strategies aimed at early intervention and resolution.
  •  Provides timely, clear and confidential grievance, investigation and disciplinary procedures.
  •  Protects staff who report bullying or cooperate in investigatory processes. 
  • Has clear repercussions for those found to exhibit bullying behaviours.

4.2.4.A process to support the implementation, review and monitoring of policy. Systems must be in place to determine the extent of bullying and harassment behaviours in an organisation or workplace and to understand the perspective and effect on those who have been harassed.

4.2.5. Systems to ensure appropriate counselling, care and support services, both internal and external, are available to assist victims of bullying and harassment.

4.2.6. An effective performance management framework and processes to avoid reasonable management actions escalating into harassment complaints.

4.3.  In addition to specific policies, medical colleges and other medical education providers must be able to demonstrate they have processes in place to work closely with relevant employers to address this issue. The roles of employers and education providers can often be blurred and collaboration is essential if these issues are to be effectively addressed. 

5.     Education and training

5.1.  Doctors at all stages in their career require further and ongoing education about what bullying and harassment looks like and how to manage bullying and harassment when and where it occurs. This include knowing how to make a complaint, and for those in management positions, how to investigate and manage a complaint.

5.2.  Education providers and employers must provide education and training to all medical students, doctors in training, doctors and other staff to assist in the recognition and resolution of issues related to bullying and harassment. Training in appropriate behaviour, resilience, performing under pressure, and how to speak up when bullying and harassment occurs must be embedded in all education and training programs, with the link between appropriate behaviour, safe working environment and patient safety clearly set out. It should also be incorporated into an organisation’s induction program, particularly for doctors in training and other new employees.6

5.3.  Managers and supervisors need to be aware of typical bullying and harassment behaviours that perpetuate an unhealthy culture and develop strategies to change those behaviours.

5.4.  While managers or supervisors have a responsibility to manage the performance of an employee or trainee professionally and constructively, many individuals are placed in leadership or supervisory roles with little or no training or support. Poor performance management of doctors, medical students and doctors in training can have a direct impact on health and wellbeing, professional confidence, career progression and satisfaction.

5.5.  Appropriate management and leadership training must be provided, and should be a requirement for those in leadership or supervisory roles. This includes education on performance management, providing constructive feedback, communicating about difficult issues, and effective complaint management to prevent issues escalating where possible.

5.6.  Skills in leadership, mentoring and management should be included in the curriculum for medical students and doctors in training and offered as continuing professional development courses for fellows. This is part of developing the qualities of professionalism and leadership in doctors, and is consistent with the attributes outlined in Good Medical Practice: A Code of Conduct for Doctors in Australia.

6.     Support and advice

6.1.  Employers, medical colleges and other medical education providers must have complaints processes in place that:

6.1.1. Provide for visible, fair and safe appeals, remediation and complaints processes.

6.1.2. Provide doctors with a safe place to bring forward complaints – free of shame, stigma or fear of repercussions.

6.1.3. Ensure that doctors are aware of how to access these processes if required.

6.1.4. Have been validated as professional, independent, confidential, and timely.

6.1.5. Result in an outcome.

6.2.  Employers, medical colleges and other medical education providers must provide doctors with access to appropriate professional debriefing, support, and mentorship services, and provide confidential counselling and support for those who have been affected by bullying and harassment.

6.3.  Where a doctor believes they are being bullied, the AMA advises that they:

6.3.1. Read their workplace bullying and complaint policy and procedures.

6.3.2. Document threats or action taken by the bully.

6.3.3. Discuss their concerns with their college, employer, supervisor or appointed contact person as appropriate.

6.3.4. Consider making a complaint under their employer’s bullying and harassment policy.

6.3.5. Seek support from their peer network, colleagues, local AMA and other organisations (e.g. the Australian Human Rights Commission), who can provide advice on their options and rights, some of which may act on their behalf.

See also

AMA Position Statement on Sexual harassment in the medical workplace - 2015

AMA Position Statement on Equal Opportunity in the Medical Workforce - 2012

End Notes


[1] Australian Human Rights Commission. Workplace bullying: Violence, Harassment and Bullying Fact sheet. Available from https://www.humanrights.gov.au/workplace-bullying-violence-harassment-and-bullying-fact-sheet

[2] Scott J, Blanshard C, Child S. Workplace bullying of junior doctors: a cross sectional questionnaire survey. NZMJ Digest. 2008. Vol 121 No 1282: 13-15.

[3] Scott K et al. ‘Teaching by humiliation” and mistreatment of medical students in clinical rotations: a pilot study. Med J Aust 2015; 203(4): 185e.1-6.

[4] EAG Report to RACS on discrimination, bullying and sexual harassment. September 2015.

[5] Law Society of NSW. Prevention of workplace bullying. A tool for change to the legal workplace (2004) at http://www.lawsociety.com.au/uploads/filelibrary/1094446976781_0.9084470... (accessed 14 January 2009)

[6] Hillis D, Watters DA. Discrimination, bullying and sexual harassment: where next for the medical leadership. Med J Aust 2015: 2-3(4); 175.

[7]Rutherford A, Rissel C. A survey of workplace bullying in a health sector organisation. Aust Health Rev. 2005;28(1):65-72.

[8] Fnais N et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med 2014; 89(5): 817-27 [abstract only].

[9] EAG Report to RACS on discrimination, bullying and sexual harassment. September 2015.

[10] Safe Work Australia (2013) Guide to Preventing and Responding to Workplace Bullying.

[11] Rosenstein AH. The Quality and Economic Impact of Disruptive Behaviours on Clinical Outcomes of Patient Care. American Journal of Medical Quality published online 21 April 2011 http://www.physiciandisruptivebehavior.com/admin/articles/25.pdf (accessed Aug 15).

[12] Askew et al. Bullying in the Australian medical workforce: cross sectional data from an Australian e-Cohort study. Australian Health Review, 2012, 36, 197–204 http://www.publish.csiro.au/?act=view_file&file_id=AH11048.pdf

[13] Hillis DJ, Grigg MJ. Professionalism and the role of the medical colleges. Surgeon 2015. [abstract only].

[14] Flynn J. Not so innocent bystanders. Med J Aust 2015; 203(4): 163.

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Published: 03 Dec 2015