Editorial

Bullying in the workplace

Could you be a bully? No? But are you

sure? Do you know what makes a bully?

Would you recognise it in others?

Even harder, would you recognise it

in yourself? Where does one cross the

fine line between being a meticulous

organiser, a good manager, a demand-

ing boss, and being a bully? Do you find

that there are some people who exas-

perate you and with whom perhaps you

are a ‘bit strict’ as a result?

So, what is bullying? Bullying is a

form of aggression. Physical bullying is

obvious and in our society tends to

be the province of children. Adults are

more subtle and devious in their

approach, and their bullying can take a

variety of forms, many of which may

not be obvious to a third party. This

allows bullies to continue their activities

unchecked and enables them to do what

they want at the expense of others.

A bully tends to be in a position of

relative power. This allows him or her

to behave towards one or many others

in an unacceptable way. This can be as

simple as making it impossible for

subordinates to progress up the career

ladder by ensuring that they are not

given opportunities. Bullies may pre-

vent a subordinate from developing

their ideas, and develop them as if they

were their own. They may manipulate

subordinates to take on unacceptable

commitments by playing on their vul-

nerabilities. This is quite common, and

the bullies may be perceived as good

managers because they get more work

done. In the medical world, bullies may

avoid taking their fair share of onerous

or unpleasant tasks in a department.

They may do this by offloading some of

these tasks onto others who are power-

less to protest. If the affected individual

does complain, the bully may threaten

to activate certain sanctions within their

power, to which the victim is vulner-

able. The situation is not unlike that of

blackmail. It is not that the victim

cannot complain; it is that they perceive

themselves as helpless, or they perceive

the consequences of their complaining

as worse than the status quo.

A picture thus emerges which we

begin to recognise. This sort of bullying

is an extension of forms of behaviour

frequently seen in the medical world.

When and where does it cross the line?

Is there then an acceptable level of

bullying [1]? Awareness of bullying as a

problem has increased, and there is

evidence that the prevalence is high

both in medicine and in the National

Health Service (NHS) more generally

[2, 3]. Nevertheless, there is also the

possibility that the behaviour experi-

enced by some as bullying is perceived

by others as normal.

A more objective – if somewhat

wordy – definition used by Swedish

workers is that bullying emerges when

one or several persons over a period of

time persistently perceive themselves to

be on the receiving end of negative

actions from one or several persons in a

situation where the one at the receiving

end has difficulty in defending him or

herself against these actions. This defi-

nition incorporates the subjective feel-

ings of the person on the receiving end,

even where an individual may have

behaved aggressively but with no inten-

tion to harm. It puts an onus on each

individual to be mindful of the effect of

their actions on others. It does not offer

protection to those falsely accused of

bullying. The main features of this

definition are (a) negative behaviours,

(b) persistence over time and (c) an

imbalance of power [4].

People who are accused of bullying

fall into two groups. The first group are

those who intend to hurt and humiliate

their victim, and who choose their

victim with a view to getting pleasure

from their power over them. This is

relatively uncommon. The second

group is made up of people who

perceive their behaviour as reasonable,

while the victim perceives it as bullying.

When individuals in this latter group are

accused of bullying they are often

mortified and suffer a major blow to

their self-esteem.

Problem situations for this second

group often relate to a senior ⁄ juniorinteraction. There are several reasons

for this. In the past, senior role models

may well have shown bullying behav-

iours. The stereotypical consultant

behaviour as depicted in Richard Gor-

don’s ‘Doctor in the House’ books was

not so far from the truth and bullying

behaviour was almost the norm – as

many could attest. In this sort of

situation the consultant may well have

come to think that bullying is normal

and acceptable behaviour. In addition,

many senior doctors are focused, dedi-

cated and, at times, obsessional individ-

uals who do not suffer fools gladly.

They are often very self-critical. They

expect equal levels of self-criticism,

dedication and focus from their junior

staff. Where the levels of activity they

require from trainees are outside the

normal range they are likely to be

accused of bullying.

Another, more recently developed

category of bully is the medical man-

ager. Frequently, they have been given

little training for the task in hand and

the demands of the system are often

unrealistic. A proportion of these doc-

tors, under pressure, may resort to any

method by which they can achieve

results, even if this amount to bullying

or blackmail. There are confidentially

reported cases of such occurrences and

bullying in the NHS is still part of the

organisational culture. For example,

even though junior doctors’ hours have

been agreed, there is, in some special-

ties, pressure to arrive early and leave

late, irrespective of the amount of work

to be done. Lastly, even normally

amiable senior doctors may behave

badly when under personal or profes-

sional stress.

Paice and Firth Cozens suggest sev-

eral causes for what we will call ‘type 2

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� 2005 Blackwell Publishing Ltd 1159

bullying’. A major reason is the lack of

training for doctors and sometimes

other managers in management or

leadership skills. In addition, they may

not appreciate that people differ [5].

The Myers-Briggs type indicator groups

people according to the way they make

decisions. One group, the ‘thinkers’

(T’s), includes 81% of males and 48%

of females. These people are often

critical and outspoken and use logical

rational analysis to make decisions. The

other group are the ‘feelers’(F’s). They

are more aware of their own and other

people’s feelings and will make their

decisions according to the values and

needs of other. T’s thrive on conflict,

F’s avoid it at all costs. T’s tend to be

more direct, whereas F’s are more

indirect (although under stress even F’s

may bully). Both of these groups need

to understand each other better.

Within the normal process of com-

munication there is also the potential for

misunderstanding on a Shakespearean

scale. An individual’s personal beliefs

and lack of self confidence will colour

their interpretation of any communica-

tion; criticism may be inferred where

none was implied. Curt behaviour by

consultants may be interpreted as criti-

cism by juniors even when this was not

intended and the consultant was merely

preoccupied with their own problems.

Where the recipient of certain critical or

aggressive behaviours is more junior and

therefore constrained in their perceived

ability to respond to it, this can be a

problem.

Self-criticism may exacerbate the

situation. Very self-critical people have

been shown to become depressed,

while individuals with low levels of

self-criticism have problems in relation-

ships with patients and colleagues.

Inculcating appropriate levels of respon-

sibility for successes and failures can help

both groups deal better with situations.

Why do victims not speak out against

bullies? If we were to speak up against

unintentional bullies, they would,

sometimes for the first time, be receiv-

ing feedback on their behaviour. Very

often (although not always) this would

motivate them to examine it and to

consider change. Overall, however,

a major disincentive is the perceived

negative consequence of any complaint.

Victims often believe that a complaint

would blight their professional progress,

and with an intentional bully this might

be the case. Thus, incentives to com-

plain are outweighed by the perceived

incentives to keep quiet. This creates a

‘survival’ culture, not too far removed

from that of prison or the armed forces.

The consequences of bullying are

far-reaching. There is evidence that it

is responsible for victims becoming

stressed, depressed and intending to

leave [6]. The 2004 study reported that

37% of doctors in training had been

bullied in the past year [3]. This

proportion is similar to the 38% annual

prevalence across the rest of the UK

workforce. The bullying was predom-

inantly by other doctors in a pecking

order of seniority, although nurses and

midwives were also implicated.

So, how can the present situation be

changed?

Although there would appear to be

a difference between intentional and

unintentional bullying, the initially

unintentional perpetrator may well

come to gain satisfaction or results from

this form of behaviour, which will then,

of course, be reinforced. Intentional

bullying is a dysfunctional form of

behaviour which needs both decisive

intervention and help.

Approaches to unintentional bullying

should be both educational and organ-

isational. Work with the individual

accused of bullying may need to include

psychotherapy to explore the reasons

for bullying or aggressive behaviour. It

should also include work on interper-

sonal and self-awareness skills so that the

bully can explore and adopt alternative

ways of behaving. This approach, while

emphasising that bullying is unaccepta-

ble, also recognises that bullying beha-

viour may, at times, be understandable

and that those using it need help to

change.

The organisational culture also needs

to change. Many Trusts have put in

place clearly defined written policies to

prevent bullying and harassment at

work, but the problem persists. This

may be in part because of increasing

NHS pressures to do more with less.

Management pressures, which essen-

tially amount to bullying, may compel

senior doctors to take on impossible

clinical loads or to work in unacceptable

facilities [7]. They may in turn adopt

bullying behaviour with subordinates in

response to these pressures. The prob-

lem may also persist because, although

there is more general awareness of the

problem, many victims still do not speak

out, for a variety of reasons. One

appalling truth is that some of these

individuals have such low self-esteem

that they do not recognise their treat-

ment as bullying.

Trusts and individual personnel need

to develop a higher level of awareness

of the problem both in others and

in themselves. Anti-bullying policies

should be given a higher profile. This

should encourage victims to come for-

ward so that individual bullies can be

identified. The unintentional bully will

usually, although not always, respond to

the strategies outlined above and modify

their behaviour. They may well respond

to personal approaches on the part of

the victim. The intentional bully needs

more careful management. Direct ap-

proach of the bully may be counter-

productive. The victim should keep a

careful record of all behaviour they

perceive as bullying. They could also

discuss it with a colleague. At this stage

it is important to ascertain that it is

bullying. Reference to the Swedish

definition may be useful here. Having

confirmed that they are dealing with

bullying they should approach the

bully’s line manager or the human

resources department. They can also

get advice from a bullying adviser, of

which there are several online, or

contact the Andrea Adams Trust. Fi-

nally, they could also approach their

professional association or trade union

for advice and support [8–11].

Diana Dickson

Consultant Anaesthetist

Leeds Teaching Hospitals Trust

References1 Houghton A. Bullying in medicine.

British Medical Journal 2003; 326:

125.

2 Quine L. Workplace bullying in ju-

nior doctors: questionnaire survey.

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1160 � 2005 Blackwell Publishing Ltd

British Medical Journal 2002; 324: 878–

9.

3 Paice E, Aitken E, Houghton A,

Firth-Cozens J. Bullying among doc-

tors in training: cross sectional ques-

tionnaire survey. British Medical Journal

2004; 329: 658–9.

4 Einharsen S, Raknes B, Mathiesen S.

Bullying and its relationship to work

and environment quality: an explor-

atory study. European Journal of Work

and Organisational Psychology 1994; 4:

381–404.

5 Paice E, Firth Cozens J. Who’s a bully

then? British Medical Journal 2003; 326:

127.

6 Firth Cozens J. Depression in doctors.

In: Katona C Robertson MM, eds.

Depression and Physical Illness. Chi-

chester: Wiley, 1997: 95–111.

7 Bruggen P. Bullying in the NHS.

BMJ.com Letters 1999; 8 February.

8 Houghton A. Tips on…dealing with

bullies. British Medical Journal Career

Focus 2005; 330: 201–202.

9 http://www.andreaadamstrust.org

[accessed on 12 October 2005].

10 http://www.successunlimited.co.uk

[accessed on 12 October 2005].

11 http://www.hse.gov.uk/stress/

standards [accessed on 12 October

2005].

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