Register      Login
Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE

Evaluating anti-bullying training in surgery: surgeons’ perceptions from Australia and Aotearoa New Zealand

Paul Gretton-Watson A * , Jodi Oakman B and Sandra G. Leggat A
+ Author Affiliations
- Author Affiliations

A School of Psychology and Public Health, La Trobe University, Bundoora, Vic 3086, Australia.

B Safety and Health, Centre for Ergonomics and Human Factors, School of Psychology and Public Health, La Trobe University, Bundoora, Vic 3086, Australia.


Australian Health Review https://doi.org/10.1071/AH24104
Submitted: 5 August 2023  Accepted: 2 August 2024  Published: 26 August 2024

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA.

Abstract

Objective

To evaluate how surgeons in Australia and Aotearoa New Zealand perceive the effectiveness of the Operating with Respect (OWR) face-to-face training program in reducing workplace bullying.

Methods

A cross-sectional survey examined the perceived effectiveness of the Royal College of Surgeons’ (RACS) face-to-face OWR training and complementary interventions in reducing workplace bullying in surgical settings. The sample included supervisory surgeons, RACS committee members, and targeted educators. The survey instrument had 35 questions, including five related to the research question. In December 2020, the survey was distributed by RACS to all surgeons who undertook OWR training between April 2017 and December 2019. Likert scales and coded free text responses were used to explore the effectiveness of face-to-face OWR training and other interventions included in the 2015 RACS Action Plan.

Results

Of the 756 surveys sent, 252 were received. The face-to-face OWR training program was rated as moderately effective. RACS’s overarching approach to anti-bullying was almost equally important, highlighting the need to consider a broader ecosystem of reform.

Conclusions

This study finds the RACS full-day anti-bullying training moderately effective in reducing bullying in surgical workplaces. However, enhancing its impact requires a sustained, multi-faceted strategy, including broader policy reforms, accountability measures, and cultural changes, to foster a long-term respectful environment in surgical settings.

Keywords: anti-bullying, bullying, disrespectful behaviour, organisational culture, surgeons, surgery, surgical workplaces, training, training programs, workplace bullying, workplace culture.

References

Zhang LM, Ellis RJ, Ma M, Cheung EO, Hoyt DB, Bilimoria KY, et al. Prevalence, Types, and Sources of Bullying Reported by US General Surgery Residents in 2019. JAMA 2020; 323(20): 2093-5.
| Crossref | Google Scholar | PubMed |

Liang R, Anthony A, Leditschke IA. Five myths about unacceptable behaviour in surgical education. ANZ J Surg 2020; 90(6): 965-9.
| Crossref | Google Scholar | PubMed |

Crebbin W, Campbell G, Hillis DA, Watters DA. Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia. ANZ J Surg 2015; 85(12): 905-9.
| Crossref | Google Scholar | PubMed |

Clements JM, King M, Nicholas R, Burdall O, Elsey E, Bucknall V, et al. Bullying and undermining behaviours in surgery: A qualitative study of surgical trainee experiences in the United Kingdom. Int J Surg 2020; 84: 219-25.
| Crossref | Google Scholar | PubMed |

Westbrook J, Sunderland N, Li L, Koyama A, McMullan R, Urwin R, et al. The prevalence and impact of unprofessional behaviour among hospital workers: a survey in seven Australian hospitals. Med J Aust 2021; 214(1): 31-7.
| Crossref | Google Scholar | PubMed |

Hu Y-Y, Ellis RJ, Hewitt DB, Yang AD, Cheung EO, Moskowitz JT, et al. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. N Engl J Med 2019; 381(18): 1741-52.
| Crossref | Google Scholar | PubMed |

Westbrook J, Sunderland N, Atkinson V, Jones C, Braithwaite J. Endemic unprofessional behaviour in health care: the mandate for a change in approach. Med J Aust 2018; 209(9): 380-1.
| Crossref | Google Scholar | PubMed |

Arianayagam R, Rashid P. Bullying among urology trainees in Australia and New Zealand: lessons from a cross-sectional survey. ANZ J Surg 2015; 85(7-8): 499-500.
| Crossref | Google Scholar | PubMed |

Fnais N, Soobiah C, Chen MH, Lillie E, Perrier L, Tashkhandi M, et al. Harassment and Discrimination in Medical Training: A Systematic Review and Meta-Analysis. Acad Med 2014; 89(5): 817-27.
| Crossref | Google Scholar | PubMed |

10  Truskett PG. Soil, seed or the tiller: why do trainees leave? ANZ J Surg 2018; 88(5): 394-5.
| Crossref | Google Scholar | PubMed |

11  Wild JRL, Ferguson HJM, McDermott FD, Hornby ST, Gokani VJ, Council of the Association of Surgeons in Training.. Undermining and bullying in surgical training: A review and recommendations by the Association of Surgeons in Training. Int J Surg 2015; 23 Suppl 1: S5-9.
| Crossref | Google Scholar | PubMed |

12  Ling M, Young CJ, Shepherd HL, Mak C, Saw RPM. Workplace Bullying in Surgery. World J Surg 2016; 40(11): 2560-6.
| Crossref | Google Scholar | PubMed |

13  El-Sayed RI, Nasr AM, Ibrahim SAE-A, Elghabbour GM. Designing Protocol for Managing Workplace Bullying among Nurses at Selected Hospitals in Port-Said City. Port Said Sci J Nur 2022; 9(3): 66-85.
| Google Scholar |

14  Akella D, Seay E. ‘Gender’ in workplace bullying: A phenomenological study on nurses. J Nurs Manag 2022; 30: 1700-12.
| Crossref | Google Scholar | PubMed |

15  Gianakos AL, Freischlag JA, Mercurio AM, Haring RS, LaPorte DM, Mulcahey MK, et al. Bullying, Discrimination, Harassment, Sexual Harassment, and the Fear of Retaliation During Surgical Residency Training: A Systematic Review. World J Surg 2022; 46(7): 1587-99.
| Crossref | Google Scholar | PubMed |

16  Huang Y, Chua TC, Saw RPM, Young CJ. Discrimination, Bullying and Harassment in Surgery: A Systematic Review and Meta-analysis. World J Surg 2018; 42(12): 3867-73.
| Crossref | Google Scholar | PubMed |

17  Jang SJ, Son YJ, Lee H. Intervention types and their effects on workplace bullying among nurses: A systematic review. J Nurs Manag 2022; 30(6): 1788-800.
| Crossref | Google Scholar | PubMed |

18  Pei KY, Cochran A. Workplace Bullying Among Surgeons—the Perfect Crime. Ann Surg 2019; 269(1): 43-4.
| Crossref | Google Scholar | PubMed |

19  Williams N, Chen M, Lee AC, Moore P, Balhatchet B, Incoll I. What are the perceptions of orthopaedic surgeons regarding leadership and leadership training? ANZ J Surg 2020; 90(1-2): 12-4.
| Crossref | Google Scholar | PubMed |

20  Einarsen S, Hoel H, Notelaers G. Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the Negative Acts Questionnaire-Revised. Work Stress 2009; 23(1): 24-44.
| Crossref | Google Scholar |

21  Einarsen S, Hoel H, Zapf D, Cooper CL, Liefooghe A. Bullying and Emotional Abuse in the Workplace: International Perspectives in Research and Practice. Wiley Subscription Services, Inc; 2004. pp. 412–4.

22  Carlasare LE, Hickson GB. Whose Responsibility Is It to Address Bullying in Health Care? AMA J Ethics 2021; 23(12): 931-6.
| Crossref | Google Scholar | PubMed |

23  Kline R, Lewis D. The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England. Publ Money Manag 2019; 39(3): 166-74.
| Crossref | Google Scholar |

24  Gretton‐Watson P, Oakman J, Leggat SG. What is the nature, extent and impact of bullying in surgical settings? Insights of surgeons in Australia and Aotearoa New Zealand. ANZ J Surg 2024; 94(1–2): 24-29.
| Crossref | Google Scholar |

25  Pan T-Y, Piscioneri F, Owen C. A quantitative analysis of the perceived barriers to implementation of multisource feedback in surgical training. ANZ J Surg 2023; 93: 1145-9.
| Crossref | Google Scholar | PubMed |

26  Royal Australasian College of Surgeons. Building Respect, Improving Patient Safety RACS Action Plan on Discrimination, Bullying and Sexual Harassment in the Practice of Surgery. Royal Australasian College of Surgeons; 2015.

27  Royal Australasian College of Surgeons. Expert advisory group report to RACS on discrimination, bullying, and sexual harassment. Melbourne: Royal Australasian College of Surgeons; 2015.

28  Braun V, Clarke V. What can “thematic analysis” offer health and wellbeing researchers? Int J Qual Stud Health Well-being 2014; 9(1): 26152.
| Crossref | Google Scholar | PubMed |

29  Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3(2): 77-101.
| Crossref | Google Scholar |

30  Braun V, Clarke V, Hayfield N. ‘A starting point for your journey, not a map’: Nikki Hayfield in conversation with Virginia Braun and Victoria Clarke about thematic analysis. Qual Res Psychol 2022; 19(2): 424-45.
| Crossref | Google Scholar |

31  Patterson E, Branch S, Barker M, Ramsay S. Playing with power: Examinations of types of power used by staff members in workplace bullying – a qualitative interview study. Qual Res Organ Manage 2018; 13(1): 32-52.
| Crossref | Google Scholar |

32  Halim UA, Riding DM. Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaviour and harassment in the surgical workplace. Br J Surg 2018; 105(11): 1390-7.
| Crossref | Google Scholar | PubMed |

33  Andrew MI, Wilkinson S, Wylie N, Salter A. Evaluation of Process Communication Model training for surgeons and other healthcare professionals: a survey. ANZ J Surg 2021; 91(4): 487-8.
| Crossref | Google Scholar | PubMed |

34  Churruca K, Pavithra A, McMullan R, Urwin R, Tippett S, Cunningham N, et al. Creating a culture of safety and respect through professional accountability: case study of the Ethos program across eight Australian hospitals. Aust Health Rev 2022; 46(3): 319-24.
| Crossref | Google Scholar | PubMed |

35  The Thread Consulting. Building Respect, Improving Patient Safety Action Plan Phase 1 Evaluation Report. Melbourne: The Thread Consulting; 2019.

36  Royal Australasian College of Surgeons. 2022 Report, Recommendations and Action Plan Building Respect, Improving Patient Safety: From Awareness to Action. Royal Australasian College of Surgeons; 2022.

37  Gillen PA, Sinclair M, Kernohan WG, Begley CM, Luyben AG. Interventions for prevention of bullying in the workplace. Cochrane Database Syst Rev 2017; 1(1): CD009778.
| Crossref | Google Scholar | PubMed |

38  Gupta P, Gupta U, Wadhwa S. Known and Unknown Aspects of Workplace Bullying: A Systematic Review of Recent Literature and Future Research Agenda. J Hum Resour 2020; 19(3): 263-308.
| Crossref | Google Scholar |

39  Hodgins M, MacCurtain S, Mannix-McNamara P. Workplace bullying and incivility: a systematic review of interventions. Int J Workplace Health Manag 2014; 7(1): 54-72.
| Crossref | Google Scholar |

40  Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open 2017; 7(11): e017708.
| Crossref | Google Scholar | PubMed |

41  Clark TR. The Hazards of a “Nice” Company Culture. Harvard Business School Cases 2022; p1-1376.
| Google Scholar |

42  Chadwick S, Travaglia J. Workplace bullying in the Australian health context: a systematic review. J Health Organ Manag 2017; 31(3): 286-301.
| Crossref | Google Scholar | PubMed |

43  Hughes AM, Zajac S, Spencer JM, Salas E. A checklist for facilitating training transfer in organizations. Int J Train Dev 2018; 22(4): 334-45.
| Crossref | Google Scholar |

44  Benmore G, Henderson S, Mountfield J, Wink B. The Stopit! programme to reduce bullying and undermining behaviour in hospitals: Contexts, mechanisms and outcomes. J Health Organ Manag 2018; 32(3): 428-43.
| Crossref | Google Scholar | PubMed |

45  Schilpzand P, De Pater IE, Erez A. Workplace incivility: A review of the literature and agenda for future research. J Organ Behav 2016; 37(S1): S57-88.
| Crossref | Google Scholar |

46  Chandrasiri S. An ideal hospital: Is leading a workforce engagement strategy the key to tackling bullying, harassment and discrimination in surgical practice? Leadersh Health Serv 2017; 30(3): 263-71.
| Crossref | Google Scholar | PubMed |

47  Nacioglu A. As a critical behavior to improve quality and patient safety in health care: speaking up. Safety Health 2016; 2(1): 10.
| Crossref | Google Scholar |

48  Fink-Samnick E. The New Age of Bullying and Violence in Health Care: Part 4: Managing Organizational Cultures and Beyond. Prof Case Manag 2018; 23(6): 294-306.
| Crossref | Google Scholar | PubMed |

49  Fink-Samnick E. The New Age of Bullying and Violence in Health Care: Part 3: Managing the Bullying Boss and Leadership. Prof Case Manag 2017; 22(6): 260-74.
| Crossref | Google Scholar | PubMed |

50  Maslach C, Leiter MP. New insights into burnout and health care: Strategies for improving civility and alleviating burnout. Med Teach 2017; 39(2): 160-3.
| Crossref | Google Scholar | PubMed |

51  Liang R, Dornan T, Nestel D. Why do women leave surgical training? A qualitative and feminist study. Lancet 2019; 393(10171): 541-9.
| Crossref | Google Scholar | PubMed |

52  Suter E, Deutschlander S, Lait J. Using a Complex Systems Perspective to Achieve Sustainable Health Care Practice Change. J Res Interprof Pract Educ 2011; 2(1): 83–99.):.
| Crossref | Google Scholar |

53  Bochatay N, Bajwa NM, Cullati S, Muller-Juge V, Blondon KS, Junod Perron N, et al. A Multilevel Analysis of Professional Conflicts in Health Care Teams: Insight for Future Training. Acad Med 2017; 92(11S): S84-92.
| Crossref | Google Scholar | PubMed |

54  Anderson RA, McDaniel Jr R. Managing Health Care Organizations: Where Professionalism Meets Complexity Science. Health Care Manage Rev 2000; 25(1): 83-92.
| Crossref | Google Scholar | PubMed |

55  Chandler J, Rycroft-Malone J, Hawkes C, Noyes J. Application of simplified Complexity Theory concepts for healthcare social systems to explain the implementation of evidence into practice. J Adv Nurs 2016; 72(2): 461-80.
| Crossref | Google Scholar | PubMed |

56  Beale D, Hoel H. Workplace bullying and the employment relationship: exploring questions of prevention, control and context. Work Employ Soc 2011; 25(1): 5-18.
| Crossref | Google Scholar |

57  Samnani A-K, Singh P. Workplace Bullying: Considering the Interaction Between Individual and Work Environment. J Bus Ethics 2016; 139(3): 537-49.
| Crossref | Google Scholar |

58  Hodgins M, MacCurtain S, Mannix-McNamara P. Power and inaction: why organizations fail to address workplace bullying. Int J Workplace Health Manag 2020; 13(3): 265-90.
| Crossref | Google Scholar |

59  Einarsen SV, Hoel H, Zapf D, Cooper CL. Bullying and Harassment in the Workplace: Theory, Research and Practice. Milton, UK: Taylor & Francis Group; 2020.

60  Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant 2022; 56(3): 1391-412.
| Crossref | Google Scholar |

61  Osier C. Workplace Bullying: Nature, Consequences, and Recommended Policies. J Organ Psychol 2021; 21(2): 70-95.
| Google Scholar |

62  Wright C. The disruptive physician and impact on the culture of safety. Curr Opin Anaesthesiol 2021; 34(3): 387-91.
| Crossref | Google Scholar | PubMed |

63  Cope A, Bezemer J, Mavroveli S, Kneebone R. What Attitudes and Values Are Incorporated Into Self as Part of Professional Identity Construction When Becoming a Surgeon? Acad Med 2017; 92(4): 544-9.
| Crossref | Google Scholar | PubMed |

64  Sharp G, Bourke L, Rickard MJFX. Review of emotional intelligence in health care: an introduction to emotional intelligence for surgeons. ANZ J Surg 2020; 90(4): 433-40.
| Crossref | Google Scholar | PubMed |

65  Abelson JS, Chartrand G, Moo T-A, Moore M, Yeo H. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015. Am J Surg 2016; 212(4): 566-72.e1.
| Crossref | Google Scholar | PubMed |