Bullying behaviour should have no place in surgical teams

Shortly after I qualified, I was told I was too nice to be a surgeon. I often think about this comment, and how shameful it is that this colleague, also an aspiring surgeon, genuinely believed it. It is this attitude that needs to change.

It is no secret that morale in hospitals is at an all-time low. Financial constraints, government targets and rising patient expectations, all contribute to ever-increasing pressures on the workforce. And this in turn can lead to strains on working relationships. Yet disruptive behaviour between members of the surgical team is not a new concept. In fact, it has been the dark secret of the profession for years now; often unreported, frequently accepted, sometimes even worn as a badge of honour.

Surgical teams have always worked in a hierarchical structure. While the introduction of the World Health Organisation (WHO) checklist for surgical procedures has made great inroads into breaking this down in the name of patient safety, this structure persists probably more than in other specialties. It has its place. When things go wrong in theatre it is important to know who is in charge, and where every team member fits in.  But it takes very strong leadership not to abuse a position of power, and in an environment where dominant behaviour often goes unchallenged, this can become the norm.

It is this acceptance of bullying behaviour that needs to be challenged. The majority of people go into healthcare for very laudable reasons, and do not display these oppressive characteristics at the start of their careers. But over time, repeated exposure to this way of working can lead to learned behaviours, which are then perpetuated. Sadly, many will not be aware that they have contributed to the problem, and would be shocked to realise that their actions have been construed as oppressive by others.

We know from the Francis and Kirkup reports on the failings of care at the Midstaffs and Morecambe Bay Trusts, that disruptive team behaviour can have catastrophic consequences on patient safety. No longer is this just about making the surgical workplace a more humane environment to work in, we owe it to our patients to tackle this problem head on.

As an organisation that exists to ensure patient safety by setting appropriate professional standards, the Royal College of Surgeons of Edinburgh (RCSEd) has launched a campaign to eliminate undermining and bullying from the surgical workplace. In 2014 a working group was set up by the College to identify the extent of the problem. The General Medical Council (GMC) trainees’ survey that year had demonstrated that surgical trainees reported the third highest incidence of bullying compared to all specialties, but the College’s own membership survey showed that this wasn’t just a problem confined to trainees. Over a third of all Members and Fellows disclosed that they had been victim to this type of behaviour, and almost 40% admitted to witnessing it. In addition, numerous reports in peer reviewed journals drew the same conclusion - bullying between members of the surgical team, but also from other colleagues within the hospital, appeared rife. 

The working group expanded and came up with practical strategies for its membership to implement, drawing on inspiration from similar work by the Royal Australasian College of Surgeons and the Royal College of Obstetrics and Gynaecology.

The aims of the RCSEd campaign are to:

1. support those who have been victims of bullying
2. get people to think about their own behaviour, how they may be contributing to the problem and offer them support to change that behaviour
3. change the culture within surgery.

The mainstay is an online hub, which includes an array of resources such as links to legal information, relevant literature, the curriculum, and case-examples of bullying behaviour. There is information for trainers on how to remain assertive without bullying or undermining a trainee. There is also advice encouraging people to reflect on their own practice and ways of interacting with colleagues. An e-module is due to launch shortly, with associated continuing professional development (CPD) accreditation, and a performance workshop is in development. Two presentations, with guidance notes attached, are available for download to be used locally by anyone who wishes to. All of these resources are available to non-members of the College, and widespread use is actively encouraged.

This initiative should not however become another stick to beat the workforce with – quite the opposite. Just as people can morph into bullies, they can change back again. It might only be a transient characteristic. Supporting people to recognise and change their behaviour is as important as supporting the victims.

No doubt surgery is a tough profession, and there is a need for some degree of resilience to cope with the physical and emotional demands of the job. But taking frustration out on someone, whoever that may be, demonstrates an underlying inability to cope. In the current climate, it is understandable that sometimes pressures can seem insurmountable.  But we need to be honest with ourselves and admit this, before risking the breakdown of our team.  Asking for help is not a sign of weakness; bullying colleagues is.

Bullying isn’t just confined to surgery, but there is a big enough problem within the profession that something needs to be done about it. The College hopes that its campaign is the start of a culture change that is long overdue.