What is the nature, extent and impact of bullying in surgical settings? Insights of surgeons in Australia and Aotearoa New Zealand

A significant body of literature has examined the impact of verbal and non‐verbal bullying in surgical settings, where a central focus has been on the experiences of trainee and junior members of the surgical team, women in surgery and other health professionals, such as nurses. Research on how surgeons' perceive or experience bullying is more limited. Therefore, this study aims to investigate the views of surgeons on negative and disrespectful verbal and non‐verbal behaviour and bullying in surgical settings, including its impact on surgeons themselves and the surgical staff they oversee.


Introduction
In 2015, the Royal Australasian College of Surgeons (RACS) formed an Expert Advisory Group (EAG) to investigate the prevalence of discrimination, bullying, and sexual harassment in surgical settings across Australia and Aotearoa New Zealand.The subsequent survey conducted revealed concerning levels of these behaviours among surgeons and surgical workplaces. 1 The RACS responded promptly by implementing an Action Plan 2 focused on promoting respect, improving patient safety, and countering unacceptable behaviours.This included the introduction of mandatory Operating with Respect (OWR) training for supervisory surgeons, committee members and targeted educators. 13][4][5][6][7] While there have been significant efforts to examine the prevalence and impact of bullying behaviour in surgical settings, 8 there is limited research on surgeons' experiences, viewpoints or role in relation to bullying in surgical environments, despite their significant positions of leadership and leverage in these settings.This study aims to explore the current perceptions of surgeons on the nature, extent and impact of bullying in their work settings.
0][11] Other behaviours include withholding pertinent information, unfair assignments, allocating undesirable tasks and indulging in sabotage. 9ndividual surgeons have different perspectives on what constitutes disrespectful and bullying behaviour and their role in how it should be managed. 9This is shaped by their seniority, level of experience, gender, surgical speciality, as well as the broader context and dynamic in each surgical setting. 12

Approach
We utilized a qualitative, phenomenological research design to investigate surgeons' lived experiences and perspectives on workplace bullying in surgical settings.This design is suitable for exploring complex and subjective issues. 13An interpretivist and inductive approach was adopted to account for multiple realities and contexts.Furthermore, we drew upon social identity theory as a theoretical framework to examine how surgeons' perceptions and roles in bullying behaviour are influenced by factors such as their seniority, gender, belonging to the RACS collectively, specific surgical specialities and diverse work settings.

Procedure
Surgeons recruited for this study were all enrolled to participate in the RACS, mandatory Operating with Respect (OWR) training workshops which targeted supervisory surgeons, RACS committee members and Foundation Skills for Surgical Educators (FSSE). 2 The workshops were run during 2018-2019.Recruitment occurred with the assistance of the RACS, through advertisements in Surgical News.In addition, registered attendees were sent reminders about the workshop they were booked to attend which included an explanation of this research and direct invitation to participate.Part A of the invitation was a request to participate in an online pre-test quantitative survey.The quantitative survey included a further invitation, part B, to participate in a 1:1 interview with the primary researcher.At all stages, consenting provisions were included and confidentiality assured.Ethical approval for this study was granted by the Science, Health & Engineering College, Human Ethics Sub-Committee at La Trobe University in August 2018 (HEC 18308).
Semi-structured interviews were conducted between February and November 2019.Surgeons were asked to focus on the 6-month period prior to their interview to avoid them potentially focusing on memorable negative events in the deeper past.The interview schedule comprised 11 questions designed to explore their direct experiences of bullying in their workplaces including where they were an agent in the negative verbal or non-verbal behaviour or were witness to the disrespectful behaviour of others.
All interviews were fully transcribed prior to analysis.The interview transcription data were initially analysed for relevant themes by the lead researcher.The two co-authors to this study then undertook an analysis of the semantic themes they identified in a shared combination of six interview transcripts with the lead researcher.This was designed to establish a foundation for the broader analysis to ensure rigour and reflexivity in the analysis.The resultant thematic map was used to guide the analysis and reporting of the interview data.

Data analyses
Interview transcripts were analysed using narrative analysis and Braun and Clarke's methodology for thematic analysis. 13NVIVO software was used to inductively code data related to semantic themes.Thematic discourse analysis was used to examine how individual surgeons derived meaning from their experiences and how their social context influenced that meaning.Data reporting followed the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist. 14

Results
Initially, 63 surgeons expressed an interest in being interviewed.After follow-up and the cancellation of some interviews (often due to urgent work matters), a total of 31 interviews were conducted (49.2%) ranging between 22 and 65 min (mean 42.03).
Nineteen male and 12 female surgeons were interviewed, including 26 Australian and 5 Aotearoa New Zealander respondents.The age range was 37-68 years (mean 51.52 years).Surgical specialties represented included: six urologists; eight paediatric surgeons (four orthopaedic and four general); four ear nose and throat surgeons; three adult orthopaedic surgeons; three general surgeons; and seven from a variety of specialties including plastics, neurosurgery, vascular and gastrointestinal surgery.
Twenty-seven interviewees worked in multiple surgical workplaces, including major public teaching hospitals and private hospitals or practices.Three respondents worked exclusively in public teaching hospitals and one respondent worked in a private setting only.

Key themes
Following thematic analysis of the interview data, three key themes emerged that addressed the research question on changes in the nature and extent of bullying behaviour and its impact on surgeons and other staff in surgical settings.The themes and subthemes are as follows: verbal bullying (five subthemes), non-verbal bullying (seven subthemes), and impact and outcomes of bullying (six subthemes).

Verbal bullying
Verbal bullying was commonly reported by respondents and is summarized in Table 1.
Respondents, primarily in public teaching settings, reported disrespectful communication and nit-picking as common in surgical workplaces.Such criticism was perceived as intense and frequent enough to constitute a pattern of bullying.Undermining and humiliation of colleagues verbally in meetings was commonly reported in some public teaching settings, and a smaller number of private hospitals, and appears to be an increasingly common way known 'bullies' dominate others.
Although raised voices and yelling were noted in stressful situations, they were generally not associated with bullying.In situations with escalated clinical risk, surgeons took charge and acknowledge they used a command-and-control communication style.The surgeons' communication was often considered contextually necessary, and thus forgiven.

Non-verbal bullying
The throwing of instruments or physical assault of theatre staff was reported to be highly unlikely by surgeons across specialties and settings.By contrast, manipulative and undermining behaviour was more commonly reported across contemporary surgical settings.This is summarized in Table 2.
Environments that were reported to be more prone to bullying were associated with factors like local leadership, level of oversight, governance and complaint reporting processes.Moreover, respondents in rural and remote health settings reported more serious cases of bullying.
Both male and female respondents commented male surgeons exhibited more overt and dominant forms of negative behaviour.Challenges varied from ensuring gender balance in conference panels to acknowledgement of the realities of balancing professional family and carer responsibilities.Despite most female respondents noting the toll 'gender' issues had taken on them through their careers, they recognized that seniority afforded them greater agency to manage moments when gender issues arose for themselves or other female staff.
Another notable finding in the data was 'bullies' reportedly coercing individuals in the broader surgical team (or hospital hierarchy) to act against a surgical team member, essentially getting someone else to do their 'dirty work'.
Respondents reported experiencing direct bullying mainly from fellow surgeons (often from a different surgical speciality), or individuals in positions of power, such as anaesthetists or senior executives in the hospital hierarchy.A range of male and female respondents across different surgical specialties, and work settings recognized that their seniority enabled greater confidence in addressing disrespectful or bullying behaviour when required while others acknowledged they actively avoid aggressive protagonists.Some respondents, across surgical specialities and work settings discussed the tactic of exploiting the complex and protracted complaints processes to 'bog down' a peer or colleague they want to undermine or sideline, describing it as a pre-emptive strike by the bully, fearing a complaint would be made against them.
A small number of respondents interviewed considered that too much emphasis is being placed on bullying in surgery.Some of these respondents reported that they wanted to be part of the study to provide balance to what they believed could be a biased narrative otherwise.

Impact and outcomes of bullying
While respondents broadly reported the intensity of bullying behaviour had reduced over time, they reflected that the impact was still felt deeply.Table 3 outlines the theme, impact and outcomes of bullying, and associated subthemes and illustrative quotes.
Many respondents, particularly working in public teaching hospitals noted, staff working in surgical setting are highly educated about workplace behaviour and sensitized to 'notice' negative and communication and behaviour.A smaller number of respondents went further believing some surgical staff are overly sensitive to criticism in any form and easily offended.
Respondents acknowledged theatre staff's awareness of the surgical workplace hierarchy, where careers can be derailed by negative relationships with more senior managers.Junior staff avoid rocking the boat and endure a lot before resorting to complaints or leaving their job.They reported avoiding problematic individuals or situations instead of complaining about or confronting them.Respondents also lacked confidence in complaints mechanisms due to barriers such as lengthy investigations, the high energy demand to see them through, and fear of negative impacts on their career.6][7] Some respondents reported feeling 'burnt' by past experiences.Many doubted the value and effectiveness of complaints processes, as they rarely led to positive change or sanctions against perpetrators.Serial bullies reportedly remain in positions of power, eroding trust in organizations and professional bodies that failed to address this known problem.
One of the most concerning findings was the acknowledged mental health impact of bullying on some respondents.A smaller subset of male respondents went as far as to report experiencing deep depression and suicidal thoughts at points in their surgical career.

Discussion
This study aimed to explore the perceptions of surgeons in Australia and Aotearoa New Zealand on the nature and extent of bullying in surgical workplaces and its impact on them and other staff working in surgical settings.
The study found evidence that respondents perceive the nature and extent of the behaviour has changed.A broad base of respondents suggesting behaviour had improved, noting a shift to becoming less intense, less physical and violent over time.While some of the more extreme forms of bullying may be consigned to history, there would appear to be a notable shift to minor incivilities, microaggressions, indirect and manipulative forms of communication and behaviour.This shift and pattern of bullying behaviour is consistent with research findings published recently in surgical workplaces notwithstanding most of this research has been conducted on Workplace bullying in surgery nursing staff, 11,15 trainee surgeons, 3,6,7,[16][17][18] medical students, 19,20 and women pursuing surgical careers. 18,21,22he other aspect of the research question related to the impact of verbal and non-verbal bullying on surgeons and staff working in surgical settings.While some respondents acknowledged their optimism about improvements in workplace communication and behaviour and belief 'things are headed in the right direction', others were less optimistic.A substantial body of research reports the negative impacts of bullying on trainee surgeons, 3,6,7,[16][17][18] female surgeons, 18,21,22 nursing staff, 11,15 and junior theatre staff but there is less published evidence that surgeons themselves are similarly impacted.
Despite the variety of reactions reported in response to personal experiences of bullying, respondents were more inclined to try to actively support and guide junior surgical staff with their negative experiences.Many participants spoke of wanting to be a good role model, positive leader and memorable to staff coming up through the ranks.There is a lack of literature on the role of surgeons as key agents in addressing workplace bullying through the lenses of leadership.
Most surgeons in this study acknowledge their crucial leadership role in their workplaces with many recognizing they 'set the tone' for what behaviour is and is not tolerated or modelled.Respondents almost universally took their leadership roles seriously and were committed to be part of the solution, focusing on improving the bullying culture in surgery in the future.This contrasts with the literature that suggests surgeons continue to be influenced by myths and practices of the past, driving poor behaviour and consistently high levels of bullying in modern surgical workplaces. 4he literature explores how social identity theory shapes surgeons' perceptions and role in bullying.This theory suggests that individuals' self-concept is influenced by their social groups, including the surgical specialties.This study found that surgeons' social identity is complex and changes over time, with some identifying more with their specialty, others with colleagues of the same gender, and others as mentors to junior staff.This lens can aid in understanding the realities and priorities of surgeons, as a potential leverage point for further positive reform.

Limitations
Respondents' past experiences of bullying may have influenced their responses during the interview, despite being asked to focus on the previous 6-months.The difficulty in setting aside these experiences may have affected the accuracy of the data collected.Although a long career and exposure to past bullying events may shape current perceptions, it could have influenced the study results.
In this study, selection bias is possible due to the methodology used to recruit surgeons.Those keen to lead the positive change may have self-selected to participate in this research.Therefore, their perspectives may not be able to be generalized to reflect the experience and voice of surgeons collectively.

Conclusion
This study examined the experiences and perspectives of surgeons across Australia and Aotearoa New Zealand about the prevalence, impact and nature, of bullying within surgical workplaces during the 6-month period prior to interviews being conducted in 2019.The findings uncovered a compelling shift in the nature and intensity of communication and behaviour, with respondents recognizing a gradual move away from overt physical and violent acts towards more insidious, covert, and manipulative forms of communication and behaviour.Although the severity of bullying may have subsided over time, its impact on the wellbeing and performance of staff working in surgical settings is still evident.In particular, the study highlights the distinct effect such behaviour has on the surgeons throughout their careers and the ongoing impact for many today.The insidious effects of subtle bullying and manipulation persist, and more must be done to address this issue.
Finally, the crucial role of surgeons as key agents in promoting and enhancing respectful communication and behaviour in surgical workplaces cannot be overstated.As a result, it is strongly advised that the RACS and employing organizations intensify their endeavours to harness the influential role of surgeons as catalysts for positive change and help build more respectful surgical workplaces.

Table 1
Description of theme 'verbal bullying' and subthemes with illustrative quotes And my colleague was just launching into him about how stupid he was'.(Respondent 12) 'And then if they speak disrespectfully, particularly if they yell or swear or abuse them, then those people aren't going to then feel safe to speak up if they see any problems which makes it a very unsafe environment'.it resulted in me crying and being yelled at ….I counted that as bullying because that kind of loud yelling, condescending behaviour, is repetitive, and makes interactions incredibly difficult at all times'.(Respondent 14) Public humiliation: undermining reputation 'He has then gone and badmouthed me further to lots of other colleagues … anything I do will be greatly criticized in front of large numbers of people'.(Respondent 30)

Table 2
Description of theme 'non-verbal bullying' and subthemes with illustrative quotes 'So, the best way that I can describe it is kind of sniping'.(Respondent 7) Body language: shunning and dismissive 'So, it's just the rolling of the eyeballs, it's the toss back of the head, which is just as powerful in terms of the gut reaction that it generates in me'.(Respondent 16) 'He was very loud and he was also very physically intimidating, because he's very tall and he was using a lot of intimidating body language, sort of standing right over her'.(Respondent 4) 'Sometimes the way we say things…trainees are not stupid, they can feel that we don't like them'.(Respondent 3) 'He has also previously physically pushed me aside in a clinic witnessed by multiple nursing staff who complained to the head of department, and nothing was done about that either'.(Respondent30) Using positional power to dominate 'So I think there's hierarchy and ego which kind of go hand-in-hand'.(Respondent19)

Table 3
Description of theme 'impact and outcomes of bullying' and subthemes with illustrative quotes I called myself out on that and apologized to them'.(Respondent 7) 'And I think people are very forgiving about it.They realize that when there's a job to be done, there's a job to be done'.(Respondent 5) Active avoidance or leave 'I think the, the most, the best mechanism I have found … is complete avoidance.So, I have set out 15 years to make sure that my paths virtually never cross with his'.(Respondent 16) Intimidation and fear of retribution 'You cannot expect the low power person to write a written complaint to HR. 'If it wasn't for my family, and for one very close friend in the institution, I can see how people could go down the path of suicide, get depressed.It was a professional nightmare'.(Respondent 13) © 2023 The Authors.ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.