[Skip to Content]
[Skip to Content Landing]

Whose Responsibility Is It to Address Bullying in Health Care?

Learning Objectives
1. Explain a new or unfamiliar viewpoint on a topic of ethical or professional conduct
2. Evaluate the usefulness of this information for health care practice, teaching, or conduct
3. Decide whether and when to apply the new information to health care practice, teaching, or conduct
1 Credit CME
Abstract

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 healthcare 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.

Case

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.

Commentary

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. Quiz Ref IDHigh-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

Quiz Ref IDThe 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

Quiz Ref IDDisrespectful 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.1216 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

Quiz Ref IDTeam members subjected to behavior like Dr T's report diminished professional satisfaction, isolation, burnout, distress, depression, anxiety, and suicidal ideation.1822 Those regularly exposed or subject to patterns of disrespect can experience pain, fibromyalgia, and cardiovascular disease.2327 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.3032 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.11,13,18,28,29,3436

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.3740

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). Quiz Ref IDTo 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.

Sign in to take quiz and track your certificates

The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Article Information

AMA Journal of Ethics

AMA J Ethics. 2021;23(12):E931-936.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Conflict of Interest Disclosure: The author(s) had no conflicts of interest to disclose.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Author Information:

  • Lindsey E. Carlasare, MBA is a research and policy manager at the American Medical Association in the Professional Satisfaction and Practice Sustainability business unit in Chicago, Illinois. Her research work focuses on identifying and evaluating elements of physician practice that contribute to burnout, stress, depression, and other factors affecting the well-being of the physician workforce. She has also collaborated on research to study practice dynamics, such as behavioral health integration, changes in payment models, and electronic health record use, and how these factors affect the practice of medicine and physician well-being; Gerald B. Hickson, MD is the Joseph C. Ross Chair of Medical Education and Administration and founding director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tennessee. He serves as a member of the board of directors of the Institute for Healthcare Improvement and previously served as chair of the board of directors of the National Patient Safety Foundation. Since 1990, his research has focused on why certain physicians attract a disproportionate share of malpractice claims, how disrespect affects team performance and outcomes of care, and how to identify and support high-risk clinicians.

References
1.
Egener  BE, Mason  DJ, McDonald  WJ,  et al.  The Charter on Professionalism for Health Care Organizations.  Acad Med. 2017;92(8):1091–1099.Google ScholarCrossref
2.
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.Google Scholar
3.
Edmondson  AC.  Wicked-problem solvers.  Harvard Business Review. June 2016. Accessed June 24, 2021. https://hbr.org/2016/06/wicked-problem-solversGoogle Scholar
4.
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
5.
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.Google ScholarCrossref
6.
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.Google ScholarCrossref
7.
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.Google ScholarCrossref
8.
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.Google ScholarCrossref
9.
Lewis  D, Gunn  R.  Workplace bullying in the public sector: understanding the racial dimension.  Public Adm. 2007;85(3):641–665.Google ScholarCrossref
10.
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.Google ScholarCrossref
11.
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.Google ScholarCrossref
12.
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.Google ScholarCrossref
13.
 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/
14.
Longo  J, Hain  D.  Bullying: a hidden threat to patient safety.  Nephrol Nurs J. 2014;41(2):193–200.Google Scholar
15.
Houck  NM, Colbert  AM.  Patient safety and workplace bullying: an integrative review.  J Nurs Care Qual. 2017;32(2):164–171.Google ScholarCrossref
16.
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.Google ScholarCrossref
17.
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.Google ScholarCrossref
18.
Sansone  RA, Sansone  LA.  Workplace bullying: a tale of adverse consequences.  Innov Clin Neurosci. 2015;12(1-2):32–37.Google Scholar
19.
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.Google ScholarCrossref
20.
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.Google ScholarCrossref
21.
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.Google ScholarCrossref
22.
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.Google ScholarCrossref
23.
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.Google ScholarCrossref
24.
Saastamoinen  P, Laaksonen  M, Leino-Arjas  P, Lahelma  E.  Psychosocial risk factors of pain among employees.  Eur J Pain. 2009;13(1):102–108.Google ScholarCrossref
25.
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.Google Scholar
26.
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.Google ScholarCrossref
27.
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.Google ScholarCrossref
28.
Kivimäki  M, Elovainio  M, Vahtera  J.  Workplace bullying and sickness absence in hospital staff.  Occup Environ Med. 2000;57(10):656–660.Google ScholarCrossref
30.
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.aspxGoogle Scholar
31.
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.Google ScholarCrossref
32.
Hickson  GB, Federspiel  CF, Pichert  JW, Miller  CS, Gauld-Jaeger  J, Bost  P.  Patient complaints and malpractice risk.  JAMA. 2002;287(22):2951–2957.Google ScholarCrossref
33.
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.Google Scholar
34.
Ayyala  MS, Rios  R, Wright  SM.  Perceived bullying among internal medicine residents.  JAMA. 2019;322(6):576–578.Google ScholarCrossref
35.
Wallace  SC, Gipson  K.  Bullying in healthcare: a disruptive force linked to compromised patient safety.  Pa Patient Saf Advis. 2017;14(2):64–70.Google Scholar
36.
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):286–296Google ScholarCrossref
37.
 Beta Heart®.  Beta Healthcare Group. Accessed June 29, 2021. https://betahg.com/risk-management-and-safety/beta-heart/
38.
 Beta Heart—care for the caregiver.  Beta Healthcare Group. Accessed June 29, 2021. https://betahg.com/beta-heart-care-for-the-caregiver/
39.
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.Google Scholar
40.
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.Google ScholarCrossref
41.
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:chap7. Accessed October 9, 2021. https://www.alphaomegaalpha.org/wp-content/uploads/2021/10/2015MedicalProfessionalism.pdfGoogle Scholar
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Close
Close
Close
Close

Name Your Search

Save Search
Close
Close

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close