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The Facts

The connection between undermining and bullying behaviour and patient safety has become clearer and less contentious over the past few years.

The evidence that this behaviour has a negative impact on the workings of a team or unit are growing. The problems of undermining and bullying extend well beyond surgery and affect the whole healthcare sector. The Illing report, published in 2013, provides a comprehensive review of the literature on the occurrence, causes, consequences, prevention and management of these behaviours in the NHS.

Being a surgeon or dentist requires far more than just technical excellence. How surgeons behave shapes the culture we work in, those we train and the profession as a whole.

The RCSEd are committed to meeting the challenges facing our profession, to change the culture within surgery and build a safer, more respectful workplace that will be beneficial for patients, trainees and all our colleagues. This involves identifying and addressing unacceptable behaviours.

 Unacceptable Behaviours


  1. Discrimination

This involves the unjust or prejudicial treatment of an individual with a particular attribute or personal characteristic, which can be legally protected.  Legislation outlines a list of attributes and characteristics against which discrimination is unlawful and these include:

  • Age
  • Sex
  • Religion or beliefs
  • Political beliefs
  • Pregnancy
  • Disabilities or impairments
  • Sexual orientation or gender identity
  • Race or cultural background
  1. Bullying

Unreasonable behaviour that creates risk to the physical or mental health or safety of an individual. This behaviour may be characterised as offensive, intimidating, malicious or insulting. Or it may be abuse or misuse of power through means that undermine, humiliate or intimidate an individual. 

It is behaviour that is repeated over time or occurs as part of a pattern of behaviour.  A one off abrupt comment is not bullying.  The behaviours are identified by the effect they have, not the intention of the perpetrator.  Some practices in the workplace may seem unfair but will not necessarily amount to bullying.

Examples of bullying include:

  • Unfair or unjust treatment
  • Intimidation, derogatory or abusive interactions
  • Denying training or promotion opportunities
  • Spreading malicious rumours
  1. Harassment

It is unwanted, unwelcome or uninvited behaviour that has the purpose of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual.  A single incident can amount to harassment. Intent or motive is irrelevant.

Examples of harassment include:

  • Negatively highlighting an individual’s physical disability
  • Derogatory comments about an individual’s beliefs
  • Unwelcome conduct of a sexual nature

Bullying itself is not against the law but harassment is.

  1. Undermining

This describes behaviour that has undermined professional confidence and/or self-esteem. 

There are clearly differences in opinions as to what is classed as discrimination, bullying, harassment and undermining.  Most will agree on extreme cases but there are “grey” areas.  The Advisory, Conciliation and Arbitration Service (ACAS) publication, 'Bullying and harassment at work' provides some guidance on this.



  1. Effective team working in health care
    West, M.A., Markiewicz, L. 2016 In: The Oxford Handbook of Health Care Management. Oxford : Oxford University Press p. 231-252. 22 p. ISBN: 9780198705109.
  2. Evidence synthesis on the occurrence, causes, consequences, prevention and management of bullying and harassing behaviours to inform decision-making in the NHS

Project title: Evidence synthesis on the occurrence, causes, consequences, prevention and management of bullying and harassing behaviours to inform decision-making in the NHS

Call to action: 10/1012 10/1012 Expedited Evidence Synthesis to support decision making by Managers and Leaders in the NHS

Chief investigator: Dr Jan Illing



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