Dr Ciaran Crowe, Trainee and member of the RCOG Workplace Behaviours Network, writes...
Bullying is ‘persistent behaviour that is intimidating, degrading, offensive or malicious and undermines the self-esteem of the recipient’. Undermining is usually taken to mean ‘lowering someone’s confidence or self-esteem’. I recite these definitions because these educational never events remain mainstream in healthcare – particularly obstetrics and gynaecology. The message that supportive learning environments produce a happy workforce which in turn drives systematic quality and patient safety is still not universal within our maternity units.
The General Medical Council (GMC) ‘State of medical education (SOMEP)’ 2016 report found that out of a sample of 150 calls made by doctors to the GMC’s confidential helpline, nearly 1 in 5 were about serious problems with bullying or undermining between doctors. GMC visits also found that in many cases, consultants were not aware doctors in training felt undermined by their actions. There is a fine line between giving objective and constructive feedback (for example during and after a surgical procedure) and giving embarrassing, intimidating feedback which lowers trainee self-esteem and puts patients at risk of harm. The breadth of this sustained problem is evident in the NHS staff survey, with 1 in 4 respondents reporting bullying year on year. The reason why can be viewed as a set of complex interacting psychosocial and cultural factors, but the common triggers for bullying are simple: high work intensity, rota gaps and poor risk/educational governance structures.
In 2012 Professor Michael West published ‘Why teamwork matters: enabling health care team effectiveness for the delivery of high quality patient care’, which led the evidence to support that bullying has a negative impact on team effectiveness and patient care. This was soon followed by the Illing report, which focused on causation and prevention. Following persistent reports that our profession is the ‘best’ at bullying, the RCOG became instrumental in driving the agenda for change. In 2013 a series of joint RCOG/Royal College of Midwives (RCM) workshops resulted in a ‘workplace behaviours’ regional network, a supportive toolkit and an eLearning package.
2015 saw a shift in gear with improved multi-organisation coordination and promotion that this behaviour is never acceptable and carries significant organisational risk. The GMC produced a useful resource – ‘Building a supportive environment: a review to tackle undermining and bullying in medical education and training.’ The Academy of Medical Royal Colleges (AoMRC) established the ‘Creating supportive environments’ working group with the aim of bringing together Department of Health (DH), Health Education England (HEE), NHS England, medical schools council, GMC and Nursing and Midwifery Council (NMC) to plan a path forward to better understand causation and implement quality metrics linked to these behaviours.
In February 2016 the Carter report’s most striking findings concerned bullying, staff sickness and turnover. Carter states that a happier workforce would save the NHS £280m per year. There has been little DH or NHS England work commissioned to understand and tackle this behaviour. As the balance of education and service needs in an ever more pressurised working environment becomes greater, the need to address this issue needs a strong political will. A squeezed service faced with a shortage of midwives and large workforce gaps of obstetricians around the country is a major contributing factor. Combine this with the increased needs of our population and suddenly the stress barometer is into the red.
I have been involved since the beginning of this journey, driven by being on the receiving end of this behaviour. I have been involved in some great work, resulting in entire organisational cultures benefiting from the creation of supportive learning environments through the use of education initiatives to: break down inter-professional barriers; flatten hierarchies; and create truly functioning teams. A team where no one is afraid to ask the difficult question and so a challenge of practice becomes the expected rather than the exception. Unfortunately, the National Training Survey (NTS) 2016 showed senior colleagues in O&G are 50% less likely to be open to an opinion from a junior colleague who disagrees with them (O&G 11%, other specialities 19%). This is reflected in an RCOG study which found that, of 44% of consultants who reported being bullied, the action was carried out by those senior or at least closest in the hierarchy. Huge geographical variation also continues to be reported.
Exploring these two issues may provide useful insight and interventions to tackle these problems. I am positive that the 2016 GMC National Trainee Survey showed a greater proportion of behavioural issues raised in O&G had been addressed, a greater number of trainees felt they were working in an environment that was supportive, respectful of each other and built their confidence. However, we continue to significantly lag behind the entire medical workforce in these areas. This is in stark contrast to the results of the first GMC National Trainer survey 2016, which found that O&G consultants were 50% more likely than the entire medical workforce trainers to believe their department was a supportive one. This disconnect between how trainees (who move through different hospitals) interpret ‘support’ compared with consultants may hold further clues to stopping bullying and undermining.
I am working with the Guardian newspaper health editorial team to develop a series on this issue. First up this summer is a national survey which aims to provide insight to causation rather than repeatedly telling us there is a problem. Only then can we identify interventions which sustainably address bullying and undermining.