Bullying in Surgery: Evidence and Impact

Having completed a very busy night shift, a Core Trainee is exhausted and struggles to present a patient’s history to the Surgical Registrar’s satisfaction. At the patient’s bedside, the Registrar, who has recently passed their FRCS exam, asks the Core Trainee several questions about the finer points of the relevant evidence base. They cannot answer any of these difficult questions. At the next bedside, the Registrar says to the patient: ‘I’d better ask you what’s been happening, this doctor doesn’t know anything’. Similar comments are made in front of the patients for the rest of the ward round.

Potential Effects

The patients may lose confidence in the Core Trainee’s ability as a doctor, and may even communicate this openly to the them. As a result, the doctor–patient relationship has been unnecessarily compromised. The Core Trainee’s confidence is likely to be affected, both by the undermining behaviour of the Registrar and by the patients’ loss of faith in their ability. The Core Trainee may become anxious about doing further post-take ward rounds with this registrar, which may threaten an important learning opportunity. In addition, the Registrar may gain a reputation as someone to be feared. If more junior staff are too anxious to confidently and clearly present important information, then the Registrar’s ability to assess and treat a patient safely may be impeded.

A general surgery registrar begins a new placement with a consultant they have not worked with before. The Consultant reads their ISCP portfolio and notices that at their previous ARCP, the trainee was recommended to repeat a year’s training to ensure they achieved their operative numbers. As the placement progresses, the consultant often asks the trainee to cover night shifts at the last minute. On one occasion, the trainee says that they cannot do the night shift as they have made other arrangements that cannot be cancelled at short notice, and that it may be fairer to employ a locum or to ask another trainee. The consultant shouts aggressively at the trainee and threatens to submit a strongly critical interim review report to the ARCP panel if they do not work the shift. These threats continue throughout the placement. In addition, the trainee overhears the consultant speaking about him to a colleague, claiming that ‘There’s no way I’d let him anywhere near my patients. Everyone who’s worked with him says that he can’t operate'.

Potential Effects

The patients may lose confidence in the Core Trainee’s ability as a doctor, and may even communicate this openly to the them. As a result, the doctor–patient relationship has been unnecessarily compromised. The Core Trainee’s confidence is likely to be affected, both by the undermining behaviour of the Registrar and by the patients’ loss of faith in their ability. The Core Trainee may become anxious about doing further post-take ward rounds with this registrar, which may threaten an important learning opportunity. In addition, the Registrar may gain a reputation as someone to be feared. If more junior staff are too anxious to confidently and clearly present important information, then the Registrar’s ability to assess and treat a patient safely may be impeded.

A scrub nurse learns that the newly employed consultant has recently become engaged to their same sex partner. During the next emergency theatre list, the nurse makes several homophobic jokes as the consultant operates. The comments continue in the coffee room at the end of the first case, in front of the other staff. The consultant asks the nurse to stop, but is told to ‘get a sense of humour’ amidst laughter. The consultant is very upset, and leaves the coffee room to begin the next case.

Potential Effects

This homophobic harassment has clear potential to threaten patients. A good relationship between the scrub nurse and the operating surgeon is vitally important if surgery is to be conducted safely. Homophobic harassment, even in the guise of humour, is illegal and victimises individuals. If the consultant in this case has been publicly harassed and humiliated, they are unlikely to be entirely focussed on the next patient’s care, particularly if they must work with the person who has harassed them. Their decision making and operative skill may be compromised, further threatening patient safety. In the longer term, the consultant may be unfairly labelled as someone who has ‘no sense of humour’, and is ‘a bit emotional’. Immediately, the relationships within the team are not conducive to effective patient care.

A newly appointed surgical consultant goes to see the Clinical Director (CD). She wishes to change her theatre list days to ensure she can leave on time every Friday evening. Unfortunately, the CD is unable to agree, as none of the other consultants can swap. The newly appointed consultant takes this very badly, is verbally abusive, and storms out of the meeting. The CD is aggrieved, but puts it down to the stress of starting as a new consultant. He calls her in for another meeting to clear the air, but this also goes badly. The consultant shouts at the CD again, and threatens to go to the GMC with allegations about the quality of his practice. This behaviour continues, with further threats made during one on one encounters around the hospital. None of the other consultants are aware of this, as the behaviour does not occur in public. The CD worries that if he alleges bullying, he will appear weak.

Potential Effects

The role of Clinical Director is an important one, and affects the whole department’s service. In this case, the bullying may be a serious distraction for the CD, and may threaten his ability to manage the department effectively. Patients are at risk from threats to his own mental health and well-being, and also from the potential disruption to the clinical service offered by the department he directs. This case also highlights the fact that any doctor is a potential victim of bullying. Seniority does not preclude it.

Three Foundation Year 1 doctors are assigned to the Plastic Surgery ward. Two of the doctors are good friends, having been to medical school together. The third is an overseas qualified doctor who is new to the NHS. Over the course of the placement, the two friends become annoyed at the pace of work undertaken by their colleague. They feel that she is slow to clerk patients, and often hands over a long list of jobs at the end of her shift. During the Foundation teaching sessions they continually discuss her alleged incompetence with their colleagues. One Friday night during handover, one of the UK-trained doctors loses her patience and shouts at her colleague in front of the nursing staff: ‘I’m sick of you handing over all these jobs. Maybe if you learnt how to speak English properly then you’d be able to do your job properly. It’d be better for everyone if you went back to your own country’.

Potential Effects

There are many potential effects of this behaviour. The undermining is likely to sap the overseas doctor’s confidence even further. It is extremely difficult to assimilate into another health care system, culture, and country, particularly if friends and family live overseas. Doctors in this position are likely to need extra support to flourish. Ultimately, a lack of confidence in one’s own practice, exacerbated by others’ undermining behaviour, is likely to negatively affect patient care as learning is inhibited by anxiety and fear. In this case, the behaviour becomes unlawful when the UK-trained doctor alleges that her colleague’s incompetence may be due to her nationality, which is a protected characteristic. On a broader scale, one third of doctors working in the NHS were trained overseas, and so a culture where these doctors are discriminated against will threaten staff recruitment and retention, and in doing so, patient care.

A female dental nurse newly recruited to a department of orthodontics in a district general hospital is asked to work with the recently appointed male specialty registrar (SpR). The relationship progresses well personally and professionally but as the weeks go by the SpR begins to bring into conversation questions regarding the nurse’s attitude to sexual practices and shares with her some of his own desires, which includes the involvement of the nurse. The nurse is upset by this topic and firmly but politely asks the SpR to desist. He laughs it off as innocent banter but persists with this line of conversation over the next few weeks. The nurse feels very threatened and, despite possible repercussions with relationships within the unit, asks for an appointment with her line manager. That meeting does not go well as the manager suggests that it is all ‘part of the job’ and that the SpR’s persistence should be ignored. She confides in another dental nurse in the department and is told ‘he does this with all his nurses – just laugh it off like the rest of us'. The nurse becomes more and more agitated when working with the SpR and she starts to lose sleep and becomes very tired and depressed. The stress becomes too much and she goes on sick leave.

Potential Effects

This inappropriate behaviour is a significant threat to the dental nurse’s mental health. The line manager has not given the support they should have and the attitude of the other dental nurses in the department demonstrates a lack of understanding of the unpleasantness and insensitivity of these conversations. The relationship between the dental nurse and the dentist is necessarily a close one and it is incumbent on the organisation and the unit to stamp out this behaviour. Separating the bullied nurse from the SpR, whilst helpful and indeed necessary is only a short-term solution. Proper counselling of all parties is required to prevent continuation and the nurse must be guaranteed there will be no repercussions as a result of her complaint. There may be grounds for formal disciplinary proceeding against the SpR.