Bullying in the New Zealand general practitioner workforce

KEYwords: Workplace bullying; bullying; general practitioners.

In recent years, there has been growing acknowledgment of a bullying problem in the health workforce. In 2015, the Royal Australasian College of Surgeons commissioned research that showed 39% of fellows, trainees and international medical graduates had experienced bullying over a 12-month period.¹ This research led to several medical colleges and unions researching the impact and potential solutions to bullying in their specialties.^2,3 Workplace bullying is defined, for the purpose of this research, as harmful behaviour, repeated over a period, from which a person struggles to defend themselves.⁴ It is the repetitive element of bullying that makes it more destructive than a one-off incident.

Bullying has considerable negative impact on individuals and the wider workplace. For individuals, it can result in anxiety, depression, lack of confidence, and result in people leaving their jobs or professions.^2,5 An often-overlooked consequence is the effect on people accused of bullying, where accusations of bullying can have negative consequences.⁶ Bullying also has a substantial financial cost. An incident of bullying involving a senior nurse is estimated to cost a District Health Board NZ$122,563 in lost efficiency.⁷ A survey from the United States reveals that many health professionals believe that disruptive behaviours have a negative impact on patient care.⁸

To date, most research into bullying in the medical workforce has been quantitative and focused on hospital-based trainees and specialists. A 2017 study of 35 general practitioners (GPs) reported 50% being exposed to negative behaviour on a weekly basis.² The Royal New Zealand College of General Practitioners (RNZCGP, the College) surveyed its members on whether they had experienced bullying in the workplace in the previous 12 months and found 11% of members reported being bullied.⁹ Although this number is lower than reported for other specialties, it nevertheless warrants further exploration. The purpose of this explorative study is to understand how bullying manifests in general practice, the responses to bullying and the impact of this behaviour.

The research perspective we adopted is critical inquiry. Critical forms of research identify and challenge current ideology with the purpose of engaging in social action for change.¹⁰ As described by Crotty and Crotty, ‘Fuelling this enterprise is an abiding concern with issues of power and oppression’.¹¹ An important goal for critical research is to establish conditions for open communication and to expose hidden power imbalances.¹² The methods used were semi-structured interviews and one focus group. These approaches were selected as they allow for a rich dataset to be collected.¹³ This research is about deeply personal issues and emotional distress within a workforce. It was considered that only qualitative methods of interviews and focus groups would provide an environment conducive to understanding the emotional perspective.

Participants were recruited by a notice in the College’s weekly newsletter, ePulse, as well as notices to relevant professional interest groups. They were offered the options to participate in an interview face-to-face, via a phone call or using Skype. There was also one focus group of three trainee GPs. The interviews generally lasted 45 – 90 min. Participants were asked about their current role, working as a GP, and any bullying experiences they have been involved in. Participants were also given the following commonly accepted modified definition of bullying: ‘a situation in which a person persistently is on the receiving end of negative actions from one or several others, in a situation where the person exposed to the negative treatment has difficulty defending him or herself against these actions.’⁴

The recordings of interviews and focus group were transcribed, and the data uploaded to NVivo11. The researchers independently coded the data using thematic analysis.¹⁴ An emergent approach was used; the researchers having no expectations of results before data analysis and interpretation. To ensure consistency of coding, researchers met throughout the analysis process to compare findings and jointly create codes. We deliberately decided against using the words ‘victim’, ‘offender’, ‘bully’ and ‘perpetrator’, as these words place added judgement on participants’ experiences and do not reflect the complexity of the social interactions.

Ethics approval was obtained from the University of Otago, identifier 17:170. Participants were offered a gift for participating in the study.

A total of 24 doctors participated in the study, all working in the scope of general practice: 63% were female and 83% were of European or Pakeha descent. Age band distribution showed 8% were aged 20–29 years, 12% were 30–39 years, 25% were 40–49 years, 38% were 50–59 years, and 17% were 60–69 years. Four were registrars in the general practice vocational training scheme.

We analysed the data according to three categories: whether participants had experienced bullying or been accused of bullying and the impact of bullying. The quotations we report reflect the best examples of issues raised and also preserve participants’ anonymity.

Participants who had been bullied reported experiencing both overt and covert forms of bullying behaviour. The overt behaviours included being yelled at, sometimes in front of patients or other staff members, threats to job security and having unfair criticism during meetings.

‘They marched me down the corridor yelling at me.’

The covert behaviours included being ignored, being reprimanded for voicing concern and the constant changing of goal-posts and targets.

‘If I attempted to talk to anybody else, they would just talk over me and ignore me, and talk so loudly you couldn’t have a conversation anyway.’

Participants who were bullied compared their experiences to a marriage break up.

‘Of course I had to leave. It was a bit like marriage: if something goes wrong in marriage you have to go through marriage counselling, it’s a pretty low chance you will get back to where you were.’

Others in similar situations employed the metaphor of a dysfunctional relationship where the person to whom aggressive behaviour is being directed tends to hold themselves responsible for the dysfunction.

‘In retrospect it is the battered wife thing, isn’t it? ‘If only I hadn’t burnt the toast, if only I had not shouted back maybe he wouldn’t of hit me’ and that’s what it felt like in the end.’

They struggled to make sense of bullying, and saw it was a form of interpersonal conflict. They described the person engaging in aggressive behaviour as someone who was ‘controlling’, ‘blunt’, or had ‘high standards’. Others viewed them as ‘horrible’ people.

There was a variety of responses to aggressive behaviour. In some cases, the response was to approach the person about their behaviour. This could result in the aggressor becoming defensive and abusive, and thus aggravating the situation. This in turn led to people on the receiving end of aggressive behaviour actively trying to avoid engagement with the person.

Others complained to managers about the aggressive person. Managers were generally dismissive of complaints and even encouraged staff to tone down their complaints. In some cases, disciplinary action did occur and the accused person became more ‘cautious’; however, they continued to bully other staff and this had a trickledown effect.

‘It has become a place where bullying is the norm. It is accepted throughout all modalities.’

Some participants subject to bullying involved employment lawyers. For some, this was a useful exercise, as lawyers advised participants of their rights and explained to them what they were going through was ‘normal’.

‘I had no idea what my rights were and it was only when I approached an employment lawyer…it cost me thousands all up. It was extremely reassuring.’

Conversely for some, involving lawyers was a costly and drawn-out exercise that added to the experience of being bullied.

Some described their practice’s response to bullying as unjust. Responses from practices included poor human resources practices such as poorly worded emails, unplanned meetings and unjustified threats to job security.

‘There was no chance of any justness or fairness to be asserted.’

When seeking help from outside the practice, people being abused were at a loss as to which organisations would be of help. Those who did manage to contact agencies, such as RNZCGP, Medical Protection Society and the Medical Council, felt disappointed and disempowered by their reported lack of interest and response.

People accused of bullying sometimes felt that the accusation of bullying was itself a form of bullying. They were not always told details of the complaint and felt they were not given a reasonable opportunity to explain their perspective. This added to sense of injustice. They also reported unpleasant work environments, being undermined and ignored.

‘I still don’t know what was said [the complaint] and I just felt that was bullying, that was a terrible bullying incident.’

‘I would say hello and they would completely ignore me.’

Again, like those who were bullied, the accused compared bullying to being like a marriage break up.

‘A bit like a bad marriage when it starts off well and then sort of things happen.’

People accused of bullying responded by isolating themselves from their colleagues and staying out of situations they would have previously become involved in.

‘I actually keep my door closed now. So I’m not as open for people coming to me anymore.’

Sometimes accused participants also employed reflective practices. One started to research bullying. This led to their reflecting on how their communication could be interpreted as bullying, even when it was never their intent to bully.

‘I actually went and read the whole ‘what a workplace bully was’ and thought I could see how somebody would perceive that.’

For another participant, being accused of bullying felt like a personal attack on themselves as a GP. At the same time, the participant acknowledged there must be some truth to the allegations, creating a sense of cognitive dissonance.

Sometimes accused people felt the need to apologise to staff, but as they were never fully told the details of complaints, it was difficult for them to know what they were apologising for.

Bullying had substantial negative impact on participants’ wellbeing. Both people bullied and accused of bullying reported feeling stressed, anxious, depressed, angry, feeling physically sick and losing weight. One participant reported being on anti-depressants and another reported post-traumatic stress disorder. For some, these impacts were long-term and receiving an email about bullying triggered them into feeling panicked about behaviour that occurred a decade ago.

‘I’m surprised because it’s in the past but then with the email asking about bullying I was shaking, so it was a big impact.’

Participants also reported bringing their stress home and their spouses’ concern witnessing what was happening to them. Bullying affected patients as their care was disrupted and their safety potentially compromised due to lack of communication between practice staff.

‘I find particularly stressful the fact that because there is poor management within the clinic you end up with patients being unsafe and I find that very stressful.’

Bullying also had a wider impact on the profession, with participants voicing confusion as how GPs could treat people in such disrespectful ways. This resulted in a loss of trust in colleagues.

‘It was also this loss of trust in colleagues. You know, we’re doctors. We’re meant to be nice people. But then I realised we have got no monopoly on niceness at all, we are no nicer than any other group of the population.’

Similar to previous research, this study confirms the substantial and long-lasting emotional harm of bullying. Although the literature mainly focuses on behaviours attributed to individuals in an organisation, our results reveal the more complex nature of the behaviour and the critical role of organisational culture in the emergence of bullying. Although our analysis split participants’ experiences into either having experienced bullying or having been accused, these categories were not static. For example, some participants found themselves in a vicious cycle where they would accuse someone of negative behaviour and the accused would then say they had been bullied by the participant. The accused would then direct harmful behaviour at the participant. Others described toxic workplaces where they were exposed to bullying from one person at the practice and then accused of bullying behaviour by someone else at the same practice. Although previous research on bullying in the GP workforce suggested prevalence of 11%, through this research, we see the impact as far greater than on only people directly involved, as it has an adverse effect on the practice community. This ‘ripple effect’ shows the value of qualitative data on drawing out the impacts of bullying and how damaging this behaviour can be.^1,2,5

The reaction of some GPs in isolating themselves from their colleagues is concerning. As an immediate response, this reaction may serve to protect people from abuse, but a long-term impact may be that it gives a message that a person does not want to be part of the practice and may have entrenched the conflict further. From a patient safety perspective, effective communication between health professionals is an essential part of safe practice. Behaviour that interferes with how a practice team communicates needs to be addressed in a timely, effective and considerate way. It is apparent from this research that more work needs to be done to upskill practice staff and managers on these communication skills.

A common thread throughout interviews was that participants felt they were not listened to, had inadequate information to make sense of the situation, and felt isolated. People experiencing bullying felt no one was held accountable and little was done to resolve the situation. Instead, they commonly felt the only option was to avoid the person or leave the practice.

In contrast, participants accused of bullying were not always sure what they were being held accountable for. This experience challenges notions that bullies always have the intent to harm. Instead, this research points to the more nuanced insight that accused people may not know the impact of their behaviour and may want to understand and change it. The reflective practices exhibited by some of the accused participants indicates a desire to make the situation better. Both accused and accuser were inhibited from engaging in constructive dialogue, which commonly led to their isolating themselves from the rest of the practice.

These accounts highlight deficiencies in human resource practice and a lack of adherence to natural justice. More training on how to address workplace conflict and bullying in the GP workforce would ameliorate many of the issues uncovered in this research. Employment rights and robust management processes should be easily accessible rather than lawyers being the only source of this information and resolution.

The overlap in experience of participants suffering and accused of bullying demonstrates how the notions of ‘bully’ and ‘victim’ are not simplistic. The rhetoric of the bully as ‘other’ is common, but does not serve as a useful beginning point of resolving conflict.¹⁵ The concepts that bullying could be due to a misunderstanding or that the accused may not understand the impact of their behaviour are absent. People have multiple perspectives in conflict situations and it is necessary to hear all sides to understand each situation. Giving people an opportunity to explain their behaviour does not mean condoning it, nor does it absolve people of responsibility and accountability. It is a better starting point than ignoring or punishing behaviour without all relevant information.

Commonly, there appears to be little effective resolution of bullying. This points to the need of new ways to approach the problem. Techniques that bring people together, such as a restorative conference, may have some promise and deserve further research. As Hutchinson argues in her article on bullying in the nursing workforce, a restorative approach would also allow everyone involved to move towards a sense of mutual participation in a solution.¹⁶

Although the authors are cautiously optimistic about the use of restorative practices, the power imbalance and harm experiences of people involved in bullying situations mean that this solution may not always be safe or feasible. The authors suggest there is a need for more support and guidance for people impacted by bullying, and a need for an independent organisation from outside of the practice to take a role in supporting the people most harmed by this behaviour.

This study has some limitations. First, as an exploratory study, it is difficult to generalise from the results as the dataset was limited. The research was based on reported experience of bullying, and more objective measures such as validated and reliable questionnaires would add depth to our understanding of incidence, prevalence and intensity of this dysfunctional behaviour. As there was self-selected entry to the study, it may be unlikely researchers would hear from people who may have intended to harm their colleagues.

This research shows that general practice is not immune from the harmful impacts of bullying. The difficulties of resolving bullying, for people both experiencing and accused of bullying, point to the need for new ways to address this behaviour. Organisational culture is an often overlooked but important factor in both the emergence and management of this disruptive behaviour. The authors suggest that a restorative approach might provide better outcomes for many cases, as it would allow for both parties to be heard and may also contribute to a more open and transparent practice environment.

The Royal New Zealand College of General Practitioners commissioned and funded this research. The views expressed in this paper are those of the authors and do not necessarily represent the position of The Royal New Zealand College of General Practitioners. While completing this study, Emma Wicks was employed as a Senior Policy Advisor at the Royal New Zealand College of General Practitioners College (June 2017–June 2019). Dr Samantha Murton undertook this research in her role as a Senior Lecturer in Primary Health Care at the University of Otago. Dr Murton was appointed President elect of the Royal New Zealand College of General Practitioners in November 2018 and President in June 2019.