Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaviour and harassment in the surgical workplace

Abuse, Bullying, Harassment, Discrimination, and Allyship in Cardiothoracic Surgery

Abuse, bullying, harassment, and discrimination are prominent workplace occurrences within cardiothoracic (CT) surgery that cause burnout and threaten the well-being of surgeons. Under-represented and marginalized groups experience higher incidences of these negative events, and CT surgery is one of the least diverse specialties. The CT surgery workforce and institutional leadership must prioritize mentorship, sponsorship, and allyship to promote a diverse and healthy specialty for surgeon recruitment, growth, and job satisfaction.

Current status of the surgical training system in Japan: results of a nationwide questionnaire survey of graduating surgical trainees

PURPOSE

To identify the problems trainees face during surgical training in Japan.

METHODS

A nationwide online questionnaire survey was conducted targeting newly certified surgical trainees.

RESULTS

The response rate was 53.8% (758/1410). Among those respondents, 25.6% were women, 71.4% were either married or had a partner, 41.3% had children, 72.7% had performed over 200 surgeries under general anesthesia, and 54.1% had chosen, before graduating from medical school, to become a surgeon. While 88.8% were interested in learning surgical techniques, 63.8% were hesitant to become a surgeon for fear of a compromised quality of private life (QOL). Conversely, only 1.4% chose their surgical training programs based on QOL. Overall, 84.6% of the trainees were satisfied with their training and this correlated with the number of surgeries performed. Only 29.9% received non-technical skill training. The average number of night shifts per month was 5.6, and 10.6% worked over 80 h per week. Harassment was reported by 41.5% of the respondents. Moreover, 33.0% had considered dropping out at some time, primarily because of their QOL (51.1%) or the harassment they had encountered (50.4%).

CONCLUSION

This survey revealed that while trainees were satisfied with the overall training system, issues such as long working hours and harassment are prevalent. Working to improve these issues could make surgery more attractive for young trainees.

Does gender affect experiences in the operating room for surgeons and anesthesiologists at a large academic center?

BACKGROUND

Although the number of women medical trainees has increased in recent years, they remain a minority of the academic workforce. Gender-based implicit biases may lead to deleterious effects on surgical workforce retention and productivity.

METHODS

All 440 attending surgeons and anesthesiologists employed at our institution were invited to complete a survey regarding perceptions of the perioperative work environment and resources. Odds ratios for dichotomous variables were calculated using logistic regressions, and for trichotomous variables, polytomous regressions.

RESULTS

243 participants (55.2%) provided complete survey responses. Relative to men, women faculty reported a greater need to prove themselves to staff; less respect and fewer resources and opportunities; more frequent assumptions about their capabilities; and a greater need to adjust their demeanor to connect with their team (p ​< ​0.05).

CONCLUSION

Perceived gender bias remains present in the perioperative environment. We need greater efforts to address barriers and create an equitable work environment.

Evolving challenges of leadership in surgery to improve inclusivity, representation, and well-being

BACKGROUND

Leadership is a complex and demanding process crucial to maintaining quality in surgical systems of care. Once an autocratic practice, modern-day surgical leaders must demonstrate inclusivity, flexibility, emotional competence, team-building, and a multidisciplinary approach. The complex healthcare environment challenges those in leadership positions. The aim of this narrative review was to consolidate the major challenges facing surgeons today and to suggest evidence-based strategies to support surgical leaders.

METHODS

Google Scholar, PubMed, MEDLINE, and Ovid databases were searched to review literature on the challenges faced by surgical leaders. The commonly identified areas that compromise inclusivity and productive leadership practices were consolidated into 10 main subheadings. Further research was conducted using the aforementioned databases to outline the importance of addressing such challenges, and to consolidate evidence-based strategies to resolve them.

RESULTS

The importance of increasing representation of marginalized groups in leadership positions, including women, ethnic groups, the queer community, and ageing professionals, has been identified by surgical colleges in many countries. Leaders must create a collegial environment with proactive, honest communication and robust reporting pathways for victims of workplace harassment. The retention of diverse, empowering, and educating leaders relies on equitable opportunities, salaries, recognition, and support. Thus, it is important to implement formal training and mentorship, burnout prevention, conflict management, and well-being advocacy.

CONCLUSION

There are two aspects to addressing challenges facing surgical leadership; improving advocacy by and for leaders. Systems must be designed to support surgical leaders through formal education and training, meaningful mentorship programmes, and well-being advocacy, thus enabling them to proactively and productively advocate and care for their patients, colleagues, and professional communities.

Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights

BACKGROUND

This observational study, paired with National Health Service (NHS) workforce population data, examined gender differences in surgical workforce members' experiences with sexual misconduct (sexual harassment, sexual assault, rape) among colleagues in the past 5 years, and their views of the adequacy of accountable organizations in dealing with this issue.

METHODS

This was a survey of UK surgical workforce members, recruited via surgical organizations.

RESULTS

Some 1704 individuals participated, with 1434 (51.5 per cent women) eligible for primary unweighted analyses. Weighted analyses, grounded in NHS England surgical workforce population data, used 756 NHS England participants. Weighted and unweighted analyses showed that, compared with men, women were significantly more likely to report witnessing, and be a target of, sexual misconduct. Among women, 63.3 per cent reported being the target of sexual harassment versus 23.7 per cent of men (89.5 per cent witnessing versus 81.0 per cent of men). Additionally, 29.9 per cent of women had been sexually assaulted versus 6.9 per cent of men (35.9 per cent witnessing versus 17.1 per cent of men), with 10.9 per cent of women experiencing forced physical contact for career opportunities (a form of sexual assault) versus 0.7 per cent of men. Being raped by a colleague was reported by 0.8 per cent of women versus 0.1 per cent of men (1.9 per cent witnessing versus 0.6 per cent of men). Evaluations of organizations' adequacy in handling sexual misconduct were significantly lower among women than men, ranging from a low of 15.1 per cent for the General Medical Council to a high of 31.1 per cent for the Royal Colleges (men's evaluations: 48.6 and 60.2 per cent respectively).

CONCLUSION

Sexual misconduct in the past 5 years has been experienced widely, with women affected disproportionately. Accountable organizations are not regarded as dealing adequately with this issue.

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis

BACKGROUND

The critical role that middle managers play in enacting organisational culture change designed to address unprofessional co-worker behaviours has gone largely unexplored. We aimed to explore middle managers' perspectives on i) whether they speak up when they or their team members experience unprofessional behaviours (UBs); ii) how concerns are handled; iii) the outcomes; and iv) the role of a professional accountability culture change program (known as Ethos) in driving change.

METHODS

Qualitative, constructivist approach. Five metropolitan hospitals in Australia which had implemented Ethos. Purposive sampling was used to invite middle-level managers from medicine, nursing, and non-clinical support services. Semi-structured interviews conducted remotely. Inductive, reflexive thematic and descriptive thematic analyses undertaken using NVivo.

RESULTS

Thirty interviews (approximately 60 min; August 2020 to May 2021): Nursing (n = 12), Support Services (n = 10), and Medical (n = 8) staff, working in public (n = 18) and private (n = 12) hospitals. One-third (n = 10) had a formal role in Ethos. All middle managers (hearers) had experienced the raising of UBs by their team (speakers). Themes representing reasons for ongoing UBs were: staying silent but active; history and hierarchy; and double-edged swords. The Ethos program was valued as a confidential, informal, non-punitive system but required improvements in profile and effectiveness. Participants described four response stages: i) determining if reports were genuine; ii) taking action depending on the speaker's preference, behaviour factors (type, frequency, impact), if the person was known/unknown; iii) exploring for additional information; and iv) addressing either indirectly (e.g., change rosters) or directly (e.g., become a speaker).

CONCLUSIONS

Addressing UBs requires an organisational-level approach beyond supporting staff to speak up, to include those hearing and addressing UBs. We propose a new hearer's model that details middle managers' processes after a concern is raised, identifying where action can be taken to minimise avoidant behaviours to improve hospital culture, staff and patient safety.

A narrative review of the physiology and health effects of burnout associated with veterinarian-pertinent occupational stressors

Chronic workplace stress and burnout are serious problems in veterinary medicine. Although not classified as a medical condition, burnout can affect sleep patterns and contributes to chronic low grade systemic inflammation, autonomic imbalance, hormonal imbalances and immunodeficiencies, thereby increasing the risks of physical and psychological ill health in affected individuals. Cultural misconceptions in the profession often lead to perceptions of burnout as a personal failure, ideas that healthcare professionals are somehow at lower risk for suffering, and beliefs that affected individuals can or should somehow heal themselves. However, these concepts are antiquated, harmful and incorrect, preventing the design of appropriate solutions for this serious and growing challenge to the veterinary profession. Veterinarians must first correctly identify the nature of the problem and understand its causes and impacts before rational solutions can be implemented. In this first part of two companion reviews, burnout will be defined, pathophysiology discussed, and healthcare and veterinary-relevant occupational stressors that lead to burnout identified.

Workplace bullying and sexual harassment among general surgery residents in Colombia

INTRODUCTION

Workplace bullying and sexual harassment are concerns among general surgery residents in Colombia.

OBJETIVE

To explore the prevalence and impact of workplace bullying and sexual harassment incidents among general surgery residents in Colombia.

MATERIALS AND METHODS

This nationwide study was conducted in 2020. Residents selfrated their exposure to workplace bullying and to sexual harassment in the forms of gender harassment, unwanted sexual attention, and sexual coercion. We analyzed demographic variables, perpetrator’s characteristics, and differences between victims and non-victims.

RESULTS

The study included 302 residents. It found that 49% of general surgery residents in Colombia suffered from workplace bullying and 14.9% experienced sexual harassment. The main forms of sexual harassment were gender harassment (47%) and unwanted sexual attention (47%). Women reported significantly higher rates of being sexually harassed. Surgeons were the main perpetrators of sexual harassment.

CONCLUSIONS

Workplace bullying and sexual harassment are frequent events in general surgery residency in Colombia. These findings suggest the need for interventions to improve the educational culture of surgical departments and decrease the prevalence of these behaviors.

Surgery should be routinely videoed

Video recording is widely available in modern operating rooms. Here, I argue that, if patient consent and suitable technology are in place, video recording of surgery is an ethical duty. I develop this as a duty to protect, arguing for professional and institutional duties, as distinguished for duties of rescueA professional duty to protect is described in mental healthcare. Practitioners have to take reasonable steps to prevent serious, foreseeable harm to their clients and others, even if that entails a non-consensual breach of confidentiality. I argue surgeons have a similar duty to patients which means that, provided the patient consents, surgery should be routinely videoed. This avoids non-consensual breaches of patient confidentiality and is aligned with stated professional obligations.An institutional duty to protect means institutions have to take reasonable steps to prevent serious, foreseeable harm at the hands of their surgeons. Rulli and Millum highlighted how institutions can meet their duty using a more consequentialist approach that balances wider interests.To test the force and scope of such duties, I examine potential impacts of routine videoing on aspects of autonomy, justice, beneficence and non-maleficence. I find routine videoing can benefit areas including safety, candour, consent and fairness in access (to surgical careers and expertise). Countervailing claims, for example, on liability, confidentiality and privacy can be resisted-such that where consent and the technology are in place, routine videoing meets a duty of easy protection In other words, its use should be standard of care.

Forum Theatre to Address Peer-to-Peer Mistreatment in General Surgery Residency

OBJECTIVE

Mistreatment is widespread in graduate medical education, and much attention has been generated on this topic and its relationship to burnout in general surgery residency. In particular, peer-to-peer mistreatment poses a developmental dilemma - as junior residents find themselves mistreated and some turn around and perpetuate that mistreatment. There is a paucity of effective interventions. Forum Theatre (FT) is a novel educational tool to engage participants in solving difficult situations. We present the use of FT as a tool to explore solutions to address peer-to-peer mistreatment in a surgery residency. FT starts with the performance of a culture-specific conflict scenario and then invites the audience to participate in renditions of the situation ending in a collective solution.

DESIGN

Stakeholder support was obtained from the general surgery program leadership. Time was protected during two 1-hour scheduled wellness didactic sessions. First, focus groups with each PG year identified the residents' experience of mistreatment. Themes regarding peer-to peer mistreatment were identified and presented to a group of 3 volunteer actor residents who chose to focus on the unintended consequences of public, corrective feedback with the understanding this would be presented to the residency at large. Following this, they developed a scenario for enactment which was implemented during the second didactic session. The enacted scenario posed a problem with public feedback ending unsatisfactorily. The audience was then invited to engage the actors and participate in replays of the situation until a collective solution was identified. Retrospective pre-post survey and a 6-month post survey were administered.

SETTING

General surgery residency at University of Texas Health San Antonio.

PARTICIPANTS

General surgery residents. 32 of 66 (48.5%) residents participated.

RESULTS

Participants noted an improved understanding of mistreatment, felt more confident in recognizing mistreatment, reported improved confidence in their ability to intervene when witnessing mistreatment and to recognize when they themselves were involved in mistreatment (p < 0.001 for all). In fact, of the residents who reported participating in mistreatment, 100% reported directing it towards peers. After the FT, 89% of residents said they "definitely" or "most likely" recommended participating in a FT to address mistreatment. 85.7% reported that the intervention was moderately to extremely effective for teaching topics in professionalism. These trends remained steady in the survey 6 months after the intervention as well.

CONCLUSIONS

We found FT was feasible to implement in a busy general surgery residency and well received with sustained, self- reported behavior change. FT is a novel tool to engage residents to self-evaluate and participate in methods to address mistreatment. FT interventions can be tailored to the local culture to address conflicts specific to that setting.

The other side of conflict: Examining the challenges of female orthopaedic surgeons in the workplace

BACKGROUND

As more women begin to enter the traditionally male-dominated field of orthopaedics, it is critical to examine their experiences in navigating gender-based conflicts in the workplace.

METHODS

An anonymous survey was distributed via a web link to approximately 1,100 members of Ruth Jackson Orthopaedic Society (RJOS) and 1,600 members of Women in Orthopaedics (WIO) Facebook group, with an estimated response rate of 50% and 50% respectively and protocols to mitigate duplicate response. Questions included demographics and presented several workplace scenarios.

RESULTS

Of the 373 respondents, 72% described experiencing some type of workplace conflict self-attributed to being female. Additionally, 8% reported either being forced out or leaving their previous job due to workplace conflict, leading to depression, anxiety, and burnout. 17% of respondents would not choose the same career again if given the opportunity.

CONCLUSIONS

Workplace conflict diminishes a surgeon's career satisfaction and may ultimately contribute to burnout. Understanding the relationship between gender bias and orthopaedic surgery is essential in moving towards change, and addressing these issues will create a more positive working environment for female surgeons.

Bullying, discrimination, and sexual harassment among intensive care unit nurses in Australia and New Zealand: An online survey

BACKGROUND

Bullying, discrimination, and sexual harassment are significant problems within healthcare organisations but are often under-reported. Consequences of these behaviours within a healthcare setting are wide ranging, affecting workplace environments, personal well-being, and patient care and leading to increased staff turnover and quality of patient care and outcomes. Whilst there has been some work undertaken in the general nursing workforce, there is a dearth of evidence regarding the extent and impact of these behaviours on the nursing workforce in intensive care units (ICUs) in Australia and New Zealand.

OBJECTIVE

We aimed to determine self-reported occurrences of bullying, discrimination, and sexual harassment amongst ICU nurses in Australia and New Zealand.

METHODS

A prospective, cross-sectional, online survey of ICU nurses in Australia and New Zealand was undertaken in May-June 2021, distributed through formal colleges, societies, and social media. Questions included demographics and three separate sections addressing bullying, sexual harassment, and discrimination.

RESULTS

In 679 survey responses, the overall reported occurrences of bullying, discrimination, and sexual harassment in the last 12 months were 57.1%, 32.6%, and 1.9%, respectively. Perpetrators of bullying were predominantly nurses (59.6%, with 57.9% being ICU nurses); perpetrators of discrimination were nurses (51.7%, with 49.3% being ICU nurses); and perpetrators of sexual harassment were patients (34.6%). Respondents most commonly (66%) did not report these behaviours as they did not feel confident that the issue would be resolved or addressed.

CONCLUSIONS

Determining the true extent of bullying, discrimination, and sexual harassment behaviours within the ICU nursing community in Australia and New Zealand is difficult; however, it is clear a problem exists. These behaviours require recognition, reporting, and an effective resolution, rather than normalisation within healthcare professions and workplace settings in order to support and retain ICU nursing staff.

Bullying in trauma and orthopaedics: a survey of staff in orthopaedic departments in the UK

Background/aims

An orthopaedic department requires good teamwork and communication to function. This is undermined by bullying and harassment, which may affect the victim's health and career.

Methods

A 26-item questionnaire was sent to all delegates who registered for a free orthopaedic webinar teaching series via email and social media. This study includes the responses from all those who had worked in a UK orthopaedic department.

Results

There were 168 respondents from varying backgrounds; 17.9% had experienced bullying or harassment in their orthopaedic department, while 36.3% had witnessed it. Women and people from ethnic minority backgrounds suffered 10.2% and 6.9% higher rates of bullying than their male or white counterparts respectively.

Conclusions

The results demonstrate that despite attempts to reduce bullying in orthopaedics, it remains prevalent, and particularly affects women and those from ethnic minority backgrounds. Orthopaedic departments must adapt to reflect changes in society.

System dynamics modeling to understand mental model of public humiliation in medical education

BACKGROUND

Mistreatment in medical school is a wicked or complex problem demonstrating inter-relatedness and dynamicity of factors that affect students. Many studies have outlined the causes, perceptions, and negative consequences of mistreatment; however, a comprehensive mental model of public humiliation, the most common type of mistreatment, is still incomplete. This study aims to provide insight into the reasons why public humiliation in medical school continues to be a problem despite existing for decades, and to propose a shift in paradigm that potentially improve these incidents.

METHOD

A systems thinking approach is used to conceptualize related components of public humiliation and student behavior. System dynamics modeling was conducted through narrative review, developing a causal loop diagram (CLD), and validation of results with 60 medical students and 40 medical educators.

RESULTS

Findings from the narrative review outlined key variables, interconnections and five emerging themes: etiology, eustress, motivation, distress, and self-esteem. The themes were conceptualized and constructed into feedback loops as a basis for the CLD. Finally, the mental model proposes three major systems underlying the consequences. The "No Pain, No Gain" illustrates the perception that stress positively drives learning, while "Stress Overload" displays the negative consequences of public humiliation. Lastly, "The Delayed Side Effect" refers to long-term side-effects on self-esteem.

CONCLUSION

The mental model illustrates how public humiliation has both immediate and delayed side-effects, simultaneously succeeding and failing at motivating student growth. Therefore, public humiliation requires continuous changes in perspective along with multiple interventions to overcome the vicious cycle.

A Study of the Relationship between Professional Communication and Professional Commitment in Operating Room Nurses

Background. Operating rooms are among the most complex clinical environments in hospitals where teamwork and professional communication play a very important part. Professional commitment is an influential factor in the personnel’s professional communication and can affect the outcomes of healthcare services. Objective. The present study aims to investigate the relationship between professional communication and professional commitment in the operating room nurses in teaching hospitals. Study Design. The present study used a descriptive-correlational design. Participants were selected via census sampling from hospitals in Shiraz over a period of three months. The participants were 350 operating room nurses who met the inclusion criteria. Data were collected using professional communication and a professional commitment questionnaire. The collected data were analyzed using the descriptive and inferential statistics in SPSS $v$ v. 22. Findings. The operating room nurses’ mean scores for professional communication (136.81 ± 13.77) and professional commitment (71.42 ± 11.62) were found to be high. The results of the Pearson correlation coefficient test showed that there was a statistically significant linear relationship between professional communication and professional commitment ( $p<0.001$ , r = 0.235). The results also showed that there was a significant relationship between professional commitment on the one hand and gender ( $p=0.042$ ), marital status ( $p=0.047$ ), and interest in work ( $p=0/000$ ) on the other hand. There was also a significant relationship between professional communication and interest in work ( $p=0/000$ ). Conclusion. Given the significance of professional communication and professional commitment in the operating rooms, it is recommended that healthcare administrators and policymakers take steps to improve these areas. It is suggested that measures should be taken to increase the personnel’s awareness of the principles of professional communication and the significance of professional commitment through regular workshops.

Harassment in surgery: line in the sand

Over the last few years, the #MeToo movement has brought attention to the long-standing culture of abuse in hierarchical organisations, and surgery is no exception. Harassment and abuse of any form should cease to be tolerated. This moment needs to be a line in the sand, the stimulus for change in our community and wider society.

Mistreatment Experiences, Protective Workplace Systems, and Occupational Distress in Physicians

IMPORTANCE

Reducing physician occupational distress requires understanding workplace mistreatment, its relationship to occupational well-being, and how mistreatment differentially impacts physicians of diverse identities.

OBJECTIVES

To assess the prevalence and sources of mistreatment among physicians and associations between mistreatment, occupational well-being, and physicians' perceptions of protective workplace systems.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was administered in September and October 2020 to physicians at a large academic medical center. Statistical analysis was performed from May 2021 to February 2022.

MAIN OUTCOMES AND MEASURES

Primary measures were the Professional Fulfillment Index, a measure of intent to leave, and the Mistreatment, Protection, and Respect Measure (MPR). Main outcomes were the prevalence and sources of mistreatment. Secondary outcomes were the associations of mistreatment and perceptions of protective workplace systems with occupational well-being.

RESULTS

Of 1909 medical staff invited, 1505 (78.8%) completed the survey. Among respondents, 735 (48.8%) were women, 627 (47.1%) were men, and 143 (9.5%) did not share gender identity or chose "other"; 12 (0.8%) identified as African American or Black, 392 (26%) as Asian, 10 (0.7%) as multiracial, 736 (48.9%) as White, 63 (4.2%) as other, and 292 (19.4%) did not share race or ethnicity. Of the 1397 respondents who answered mistreatment questions, 327 (23.4%) reported experiencing mistreatment in the last 12 months. Patients and visitors were the most common source of mistreatment, reported by 232 physicians (16.6%). Women were more than twice as likely as men to experience mistreatment (31% [224 women] vs 15% [92 men]). On a scale of 0 to 10, mistreatment was associated with a 1.13 point increase in burnout (95% CI, 0.89 to 1.36), a 0.99-point decrease in professional fulfillment (95% CI, -1.24 to -0.73), and 129% higher odds of moderate or greater intent to leave (odds ratio, 2.29; 95% CI, 1.75 to 2.99). When compared with a perception that protective workplace systems are in place "to a very great extent," a perception that there are no protective workplace systems was associated with a 2.41-point increase in burnout (95% CI, 1.80 to 3.02), a 2.81-point lower professional fulfillment score (95% CI, -3.44 to -2.18), and 711% higher odds of intending to leave (odds ratio, 8.11; 95% CI, 3.67 to 18.35).

CONCLUSIONS AND RELEVANCE

This survey study found that mistreatment was common among physicians, varied by gender, and was associated with occupational distress. Patients and visitors were the most frequent source, and perceptions of protective workplace systems were associated with better occupational well-being. These findings suggest that health care organizations should prioritize reducing workplace mistreatment.

Workplace bullying in surgical environments in Saudi Arabia: A multiregional cross-sectional study

BACKGROUND

Workplace bullying (WPB) is any sort of repeated and unjustified verbal, sexual, or physical intimidation that a person is exposed to by a group or another person in the workplace. In healthcare environments, practitioners are occasionally victims of WPB incidents. Bullying in surgical environments is an important issue that needs attention as it could affect patient care either directly or indirectly. The objective of this study was to assess the prevalence of bullying in surgical environments in multiple regions in Saudi Arabia.

MATERIALS AND METHODS

This cross-sectional study was conducted among surgeons, trainees, interns, nurses, and students in surgical specialties in multiple Saudi regions. The survey was designed by Survey Monkey and posted online. The data were analyzed through SPSS Version-21 by computing descriptive statistics as frequency and percentages with graph construction.

RESULTS

About two-thirds (65.2%) of the 788 study participants were male and were between the age of 20 and 29 years (67.8%). Consultants came first as perpetrators of bullying in the past 12 months (44.3%) and residents and interns were the major victims. The NAQ-R score ranged from 22.00 to 110.00, with a mean score of 42.47 (SD=17.9). Statistically significant association was found between mean NAQ-R score and age (P = 0.007), specialty (P = 0.002), and position (P < 0.001).

CONCLUSION

WPB is a pervasive problem in surgical environments in multiple regions of Saudi Arabia. Consultants and specialists are the primary offenders in bullying, which makes the hospital an environment for bullying behaviors.

#SpeakUpOrtho: Narratives of Women in Orthopaedic Surgery-Invited Manuscript

Microaggressions, bullying, harassment, sexual harassment, and discrimination continue to be experienced by orthopaedic physicians in the workplace. Oftentimes, these behaviors go unreported because of fear of retaliation, and many perpetrators are not held accountable. This article provides examples of stories anonymously submitted to #SpeakUpOrtho on the topics of microaggressions, bullying/harassment, sexual harassment, discrimination, and retaliation by orthopaedic surgery residents, fellows, and attending surgeons. Commentary by experts in the field is also included to provide ways to manage and prevent the perpetuation of these behaviors.

Supervisors' transformational leadership style and residents' job crafting in surgical training: the residents' views

OBJECTIVES

This study aims to explore the effects of three supervisors' leadership styles (transformational, transactional, and laissez-faire) on residents' job crafting.

METHODS

Sequential explanatory mixed-methods. First, a purposive sample of residents rated the leadership style of their supervisors and their own job crafting on the Multifactor Leadership Questionnaire and the Dutch Job Crafting Scale. The effects were tested through linear mixed effects regression analysis. Thereafter we conducted semi-structured interviews with residents and conducted a thematic analysis.

RESULTS

A total of 116 residents participated. A transformational style had a positive effect on residents' job crafting (b = .19, t₍₁₁₂₎ =3.76, p=. 009), whereas the transactional and laissez-faire styles did not. This could be explained by the fact that residents felt a positive influence of the supervisors with such style on the atmosphere for training, on the job resources available to them, and on their modelling function for how to handle the demands of the environment.

CONCLUSIONS

A transformational style of the supervisor has a positive effect on residents' job crafting. Future research should explore the supervisors' perspective, as well as the effectiveness of leadership training for supervisors with a focus on resident outcomes, such as job crafting.

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review

Background

Recent studies suggest that displays of unacceptable behaviour, including bullying, discrimination and harassment, between healthcare workers (HCWs) may impair job performance, and in turn, increase the frequency of medical errors, adverse events and healthcare-related complications. The objective of this systematic review was to summarise the current evidence of the impact of unacceptable behaviour occurring between HCWs on clinical performance and patient outcomes.

Methods

We searched MEDLINE, Embase, PsycINFO and CINAHL from 1 January 1990 to 31 March 2021. The search results were screened by two independent reviewers and studies were included if they were original research that assessed the effects of unacceptable behaviour on clinical performance, quality of care, workplace productivity or patient outcomes. Risk of bias was assessed using tools relevant to the study design and the data were synthesised without meta-analysis.

Results

From the 2559 screened studies, 36 studies were included: 22 survey-based studies, 4 qualitative studies, 3 mixed-methods studies, 4 simulation-based randomised controlled trials (RCTs) and 3 other study designs. Most survey-based studies were low quality and demonstrated that HCWs perceived a relationship between unacceptable behaviour and worse clinical performance and patient outcomes. This was supported by a smaller number of higher quality retrospective studies and RCTs. Two of four RCTs produced negative results, possibly reflecting inadequate power or study design limitations. No study demonstrated any beneficial effect of unacceptable behaviour on the study outcomes.

Conclusions

Despite the mixed quality of evidence and some inconsistencies in the strengths of associations reported, the overall weight of evidence shows that unacceptable behaviour negatively affects the clinical performance of HCWs, quality of care, workplace productivity and patient outcomes. Future research should focus on the evaluation and implementation of interventions that reduce the frequency of these behaviours.

Examining the views of operating room nurses and physicians on the relationship between professional values and professional communication

Purpose

Professional communication and professional values are two basic concepts in operating rooms and should be studied more closely in view of the nature of work and the high circulation of patients in operating rooms.

Methods

The present work is a descriptive-analytic study with a cross-sectional design. The sample was 603 operating room physicians and personnel selected from the public hospitals of Shiraz. The data collection instruments were the 41-item professional communication questionnaire and the 26-item professional values scale.

Results

The results showed that the operating room nurses and physicians perceived the status of professional communication and professional values to be satisfactory. As for professional communication, the participants’ perception of the domains of mutual respect and trust (p ≤ 0.001), teamwork (p ≤ 0.001), ethical competence (p ≤ 0.017), and workplace conflicts (p ≤ 0.001) was significant. As for professional values, only the dimension of care (p ≤ 0.016) was perceived to be significant. Moreover, a significant positive relationship was found to exist between professional communication and professional values (p ≤ 0.001).

Conclusion

Considering the significance of the concept of professional communication and its connection with professional values, it is recommended that operating room personnel and physicians receive systematic education about professional communication and the harms of destructive attitudes as part of their academic education and afterwards.

Bullying, Discrimination, Harassment, Sexual Harassment, and the Fear of Retaliation During Surgical Residency Training: A Systematic Review

BACKGROUND

The negative effects of bullying, discrimination, harassment, and sexual harassment (BDHS) on well-being and productivity of surgical residents in training have been well documented. Despite this, little has changed over the past decade and these behaviors continue. The purpose of this study was to determine the prevalence of each abusive behavior experienced by residents, identify the perpetrators, and examine the reporting tendency.

METHODS

A systematic review of articles published between 2010 and 2020 in the MEDLINE, EMBASE, and Cochrane databases was performed following PRISMA guidelines. The following search terms were used: bullying, harassment, sexual harassment, discrimination, abuse, residency, surgery, orthopedic surgery, general surgery, otolaryngology, obstetrics, gynecology, urology, plastic surgery, and training.

RESULTS

Twenty-five studies with 29,980 surgical residents were included. Sixty-three percent, 43, 29, and 27% of surgical residents experienced BDHS, respectively. Female residents reported experiencing all BDHS behaviors more often. Thirty-seven percent of resident respondents reported burnout, and 33% reported anxiety/depression. Attending surgeons, followed by senior co-residents, were the most common perpetrators. Seventy-one percent did not report the behavior to their institution. Fifty-one percent stated this was due to fear of retaliation. Of those who reported their experiences, 56% stated they had a negative experience reporting.

CONCLUSION

Our review demonstrates high prevalence rates of BDHS experienced by residents during surgical training, which have been associated with burnout, anxiety, and depression. The majority of residents did not report BDHS due to fear of retaliation. Residency programs need to devise methods to have a platform for residents to safely voice their complaints.

A qualitative study of hospital clinical staff perceptions of their interactions with healthcare middle managers

PURPOSE

The authors explored clinical staff perceptions of their interactions with middle management and their experiences of the uncongeniality of their working environment.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews of clinical staff from an Australian public health service's Emergency, Surgery and Psychiatry departments. Volunteer interview transcripts were inductively coded using a reflexive thematic content analysis.

FINDINGS

Of 73 interviews, 66 participants discussed their interactions with management. Most clinicians considered their interactions with middle management to be negative based on a violation of their expectations of support in the workplace. Collectively, these interactions formed the basis of clinical staff perceptions of management's lack of capacity and fit for the needs of staff to perform their roles.

PRACTICAL IMPLICATIONS

Strategies to improve management's fit with clinicians' needs may be beneficial for reducing uncongenial workplaces for healthcare staff and enhanced patient care.

ORIGINALITY/VALUE

This article is among the few papers that discuss interactions with management from the perspective of clinical staff in healthcare. How these perspectives inform the perception of workplace uncongeniality for clinicians contributes greater understanding of the factors contributing to adversarial relationships between clinicians and managers.

Zero tolerance to sexual harassment in surgical training in the UK

Sexual harassment exists within the surgical training community and environment. This is unprofessional behaviour and the surgical community must raise awareness of it as well as facilitating and encouraging reporting with robust investigation pathways.

Repeated bullying at the workplace in medical students and young doctors: the MESSIAEN national study

Despite clues indicating high Bullying at the Work Place (BWP) rates in French hospitals, there has been no quantitative study so far. To determine the prevalence of repeated BWP in a national sample of French young physicians; its risk factors, and the mental health consequences of BWP. The study is a cross-sectional observational epidemiological national study addressed to young physicians. The online internet anonymous questionnaire was elaborated according to previous studies exploring BWP. In addition, we explored the quality of initial training. BWP was defined according to the French legal definition. Mental health was assessed by Hamilton Anxiety and Depression scale, psychotropic drug consumption and psychotherapy follow-up. A Structured Equation Modeling (SEM) was carried out to confirm our theoretical model. 2003 participants of the 37 French medical faculties were included. At least one history of BWP was identified in 41.7% of the participants. The SEM model showed good fit (RMSEA = 0.025, CFI = 0.93, TLI = 0.92, WRMR = 1.285). In the SEM model, BWP was associated with age and number of monthly night shifts and weekly worked hours. Obstetric gynecology, psychiatry, surgery, and medical specialties and low-quality initial training were associated with higher risk of BWP. BWP was associated with increased anxiety and depressive symptoms, daily antidepressant and anxiolytic consumption, and psychotherapy follow-up. Decreasing worked hours and night shifts and improving the quality of the initial training may help preventing BWP among medical students and young physicians. Obstetric gynecology, surgical and medical specialties, and psychiatry should be targeted with a focus on developing prevention programs.

Sexual orientation, gender identity, and gender expression: From current state to solutions for the support of lesbian, gay, bisexual, transgender, and queer/questioning patients and colleagues

Many of the systemic practices in medicine that have alienated lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals persist today, undermining the optimal care for these patients and isolating LGBTQ medical providers from their colleagues. The 2020 Task Force on Diversity, Equity, and Inclusion Report recently published by the Society for Vascular Surgery marked the first publication advocating for the inclusion of sexual orientation and sexual identity in the development of initiatives promoting and protecting diversity across vascular surgery. Vascular providers should be aware that it is crucial to cultivate an environment that is inclusive for LGBTQ patients because a large proportion of these patients have reported not self-disclosing their status to medical providers, either out of concern over potential personal repercussions or failing to recognize the potential relevance of LGBTQ status to their medical care. Safe Zone training has provided a standard resource for providers and staff that can be integrated into onboarding and routine training. Clarifying the current terminology for sexual orientation and identity will ensure that vascular providers will recognize patients who could benefit from screening for additional vascular risk factors relevant to this population related to sexual health, social behavior, physical health, and medical therapies. The adoption of gender neutral language on intake forms and general correspondence with colleagues is key to reducing the unintended exclusion of those with LGBTQ identities in both inpatient and outpatient environments. In many locales across the United States, the professional and personal repercussions for openly reporting LGBTQ status persist, complicating efforts toward quantifying, recognizing, and supporting these patients, practitioners, and trainees. Contributing to an inclusive environment for patients and peers and acting as a professional ally are congruent with the ethos in vascular surgery to treat all patients and colleagues with respect and optimize the healthcare of every vascular patient.

Exploring the Impact of the Surgical Exploration and Discovery (SEAD) Program on Medical Students' Perceptions of Gender Biases in Surgery: A Mixed-Method Evaluation

OBJECTIVE

Female representation in surgery is increasing; however, many surgical specialties continue to observe disproportionately fewer females entering their residencies. This study assesses how medical students' gender-based perceptions of surgical careers are impacted by attending the Surgical Exploration and Discovery (SEAD) program, a 2-week, immersive procedural program that offers observerships, mentorship, and workshops across 8 surgical specialties.

DESIGN

In this mixed-method prospective cohort study, medical students' awareness, beliefs, and experiences of gender bias in surgery were assessed using a 10-item Gender Bias in Medical Students Assessment-Surgery (GBMSA-S) psychometric survey instrument inspired by the validated Gender Bias in Medical Education Scale (Parker et al., 2016).

SETTING

Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada.

PARTICIPANTS

Eighteen first-year medical students in the experimental group (8 male, 10 female) and 18 in the control group (7 male, 11 female).

RESULTS

Compared to the control group, SEAD participants had significant changes in agreement with the statements: "surgery is male-dominated," "medical studies are mainly done in males," "gender discrimination is more pronounced in surgery than other medical professions," "consideration of my gender is an important factor in whether or not to pursue surgery as a career," and "I have encountered gender-biased attitudes and/or behaviors among non-physician health care staff" (p < 0.05). Perceptions of gender bias were reduced post-SEAD. Subgroup analysis by gender suggested that the significance of these changing perspectives was due to female participants' responses. SEAD also produced an increase in the level of interest in surgery (p = 0.04). Receptive and authentic dialogue was identified as a critical step toward social inclusivity (n = 11).

CONCLUSIONS

Early surgical exposure through SEAD produces a statistically significant increase in surgical interest and reduces certain perceptions of gender bias in surgery, particularly among female medical students.

Discrimination in the surgical discipline: an international European evaluation (DISDAIN)

Background

Negative workplace experiences (NWPEs), such as gender discrimination, bullying, sexual harassment and ethnic discrimination, are concerns in today’s surgical society. These negative experiences potentially impair surgeons’ performance and might impact patient care or outcomes negatively. This study aimed to assess the experience of NWPEs across the European surgical workforce.

Methods

A prospective online 34-point questionnaire was designed using a combination of Likert scale, multiple-choice and short-answer questions. Invitations were distributed through surgical associations via email/social media between 1 September and 15 November 2019. Data were analysed using non-parametric methods.

Results

Some 840 complete responses were included in the analysis. The distribution across genders and stage of surgical training was even. Of the respondents, 20 per cent (168 respondents) considered quitting their job, 4.5 per cent (38) took time off and 0.5% (4) left surgery due to NWPEs; 12.9 per cent of females and 4.4 per cent of males experienced some form of physical harassment. Females and those in training were significantly more likely to experience or witness gender discrimination and sexual harassment. Just over half of the respondents (448) did not report negative experiences, with most of these (375 respondents) being unaware of whom to report to. Nearly a fifth of respondents felt that NWPEs influenced patient care or outcomes negatively.

Conclusion

NWPEs were frequent, especially among females and those in training. While a substantial proportion of respondents experienced physical harassment, many individuals were unaware of how to raise concerns. Adverse effects on patient outcomes, surgical training and workforce retention indicate a need for urgent action.

How Surgical Leaders Transform Their Residents to Craft Their Jobs: Surgeons' Perspective

BACKGROUND

Surgeons should transform their residents to take the lead in their jobs and optimize their working conditions, so-called job crafting. We investigated the actions undertaken by surgeons with a transformational leadership style to encourage residents' job crafting, about which there is at present a paucity of information.

METHODS

We performed a qualitative study based on principles of constructivist grounded theory. In-depth interviews were held with a purposive sample of surgeons who were perceived as transformational leaders by their residents. During data analysis (open, axial, and selective coding), we compared inductive codes with deductive codes drawn from the job demands-resources and transformational leadership theories to reach a consensus on the interpretation of data and identification of the main themes.

RESULTS

Sixteen surgeons participated. Surgeons undertook five actions that enhanced job crafting in residents. They: one) modeled positive behaviors of a good surgeon; two) used a stepwise individual approach toward autonomy; three) connected with the resident as a person; four) supported residents in handling complications and errors; and five) they coached the resident to deal with competing interests. These actions had four consequences for residents. They led to: one) more responsibilities in patient care; two) more constructive relationships in the workplace; three) less pressure from workload and surgical care duties; and four) less personal difficulties and errors in patient care.

CONCLUSIONS

The actions undertaken by surgeons with a transformational leadership style have a positive association with the residents' ability to craft their jobs. This knowledge has implications for surgeons' leadership development with a view to workplace education.

Attrition From a National Surgical Training Program: A Qualitative Analysis

OBJECTIVE

The objective of this study was to examine the trainee experience to identify some of the factors which contribute to attrition from surgical training.

SUMMARY BACKGROUND

Not all trainees who commence a surgical training program continue and complete it. Surgical training can be personally and professionally demanding and trainees may, for a multitude of reasons, change career direction. Attrition from surgical training impacts upon multiple stakeholders: A decision to leave may be difficult and time consuming for the individual and can generate unanticipated inefficiency at a systems level. This project examined attrition from a national surgical training program to deepen understanding of some of the causes of the phenomenon.

METHODS

A qualitative study was performed. A purposeful sampling strategy was used to identify representative participants. Semistructured interviews were conducted with eleven trainees who withdrew or considered doing so. A thematic analysis was performed to examine the experiences of trainees and explore the factors which influenced a decision to withdraw.

FINDINGS

Five major themes emerged from the interview data: delivery of training, the training atmosphere, influence of seniors, concerns regarding progression, and the perception of the future role with respect to lifestyle.

CONCLUSIONS

The personal experience of surgical training is crucial in informing a decision to withdraw from a program. Voluntary attrition is appropriate where doctors, after experiencing some time in surgical training, recognize that a surgical career does not meet their expectation. However, improving the delivery of training by addressing the concerns identified in this study may serve to enhance the personal training experience and hence maximize retention.

The unspoken reality of gender bias in surgery: A qualitative systematic review

OBJECTIVE

This study was conducted to better understand the pervasive gender barriers obstructing the progression of women in surgery by synthesising the perspectives of both female surgical trainees and surgeons.

METHODS

Five electronic databases, including Medline, Embase, PsycINFO, CINAHL and Web of Science Core Collection, were searched for relevant articles. Following a full-text review by three authors, qualitative data was synthesized thematically according to the Thomas and Harden methodology and quality assessment was conducted by two authors reaching a consensus.

RESULTS

Fourteen articles were included, with unfavorable work environments, male-dominated culture and societal pressures being major themes. Females in surgery lacked support, faced harassment, and had unequal opportunities, which were often exacerbated by sex-blindness by their male counterparts. Mothers were especially affected, struggling to achieve a work-life balance while facing strong criticism. However, with increasing recognition of the unique professional traits of female surgeons, there is progress towards gender quality which requires continued and sustained efforts.

CONCLUSION

This systematic review sheds light on the numerous gender barriers that continue to stand in the way of female surgeons despite progress towards gender equality over the years. As the global agenda towards equality progresses, this review serves as a call-to-action to increase collective effort towards gender inclusivity which will significantly improve future health outcomes.

Forgiveness: protecting medical residents from the detrimental relationship between workplace bullying and wellness

Bullying of medical residents is associated with numerous negative psychological and physiological outcomes. As bullying within this demographic grows, there is increased interest in identifying novel protective factors. Accordingly, this research investigated whether interpersonal forgiveness buffers the relationship between two forms of workplace bullying and indices of well-being. Medical residents (N = 134, 62% males) completed measures assessing person and work-related bullying victimization, dispositional forgiveness, and depressive symptoms and underwent a series of cardiovascular assessments during which cardiovascular reactivity was induced by a 3-min serial subtraction math task. It was hypothesized that the tendency to forgive would be negatively related to bullying victimization and that forgiveness would reduce the association of bullying with psychological distress (i.e. depressive symptoms), cognition errors (i.e. incorrect serial subtraction computations), and exaggerated cardiovascular reactivity and recovery. Findings show that forgiveness reduced the harmful relationship between the two forms of workplace bullying and depressive symptoms, serial subtraction errors, and cardiovascular reactivity and recovery for systolic blood pressure (SBP). Study results suggest that forgiveness may serve as an effective means for reducing the outcomes of bullying for medical residents. Implications for forgiveness interventions are discussed. Lay summary This research demonstrated that forgiveness reduced the harmful relationship between bullying victimization and negative outcomes (i.e. depressive symptoms, subtraction errors, and exaggerated cardiovascular reactivity and recovery for SBP) in medical residents. This study suggests that forgiveness may serve as a protective factor and provide an effective means for reducing the negative association between workplace bullying and negative outcomes.

Bullying, harassment and sexual discrimination among ophthalmologists in Australia and New Zealand

BACKGROUND

Discrimination, bullying and sexual harassment (DBSH) impact the psychological well-being of doctors and contribute to poor health outcomes. The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) commissioned independent surveys to evaluate DBSH among members/trainees.

METHODS

Anonymous online surveys by Best Practice Australia were undertaken in 2015 and 2018. Cross-sectional analysis was prevalence of perceived DBSH, rates of reporting, intervention and resolution undertaken. Response rate was 50% (658/1319) in 2015 and 40% (557/1401) in 2018. In both surveys, 29% were female. This is representative of the distribution of the RANZCO members.

RESULTS

In a 2015 survey, 37.6% of respondents experienced DBSH, with prevalence being the highest for females (62.3%; N = 104 cf males 27.7%; N = 167) and trainees (49.2%; N = 61). In 2018, 49.2% of respondents reported DBSH with rates low for all forms of DBSH (22%-29%). Sexual harassment was reported by 12% and the least discussed or reported. Respondents strategy for taking action included draw on personal support network (25-43%), official complaints to supervisors (16-22%), human resources (2%-10%) and RANZCO (0%-6%). Reasons for not taking action included fear of impact of future career options (54.1%-60.7%), fear of victimization (35.7%-50.4%) and afraid of not being believed (31.9%-52.4%). Satisfactory resolution rates were 6% to 25%. A majority of respondents (77%) were positive about RANZCO initiatives.

CONCLUSIONS

DBSH is commonly reported by RANZCO members with female ophthalmologists more than two times more likely to experience any one of the four behaviours, three times more likely to experience discrimination and six times for sexual harassment. Fear of compromising personal and career progression contribute to low levels of reporting.

The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies

AIMS

Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, and to investigate interventions countering such behaviours.

METHODS

A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database in April 2020, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to which we adhered. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were included for review.

RESULTS

Of 570 papers, 27 were eligible for inclusion. These were published between 1998 and 2020. A narrative review was performed in light of the significant heterogeneity displayed by the eligible studies. A total of 13 papers discussed the prevalence of GBSD, while 13 related to the impact of these behaviours, and six discussed mitigating strategies. GBSD was found to be common in the orthopaedic workplace, with all sources showing women to be the subjects. The impact of this includes poor workforce representation, lower salaries, and less career success, including in academia, for women in orthopaedics. Mitigating strategies in the literature are focused on providing female role models, mentors, and educational interventions.

CONCLUSION

GBSD is common in orthopaedic surgery, with a substantial impact on sufferers. A small number of mitigating strategies have been tested but these are limited in their scope. As such, the orthopaedic community is obliged to participate in more thoughtful and proactive strategies that mitigate against GBSD, by improving female recruitment and retention within the specialty. Cite this article: Bone Joint J 2020;102-B(11):1446-1456.

Association Between Workplace Bullying Occurrence and Trauma Symptoms Among Healthcare Professionals in Cyprus

Workplace bullying/mobbing is an extreme work-related stressor, but also a severe hazard for physical, mental and psychological health in healthcare employees, including nurses. A range of trauma-related symptoms has been linked with bullying victimization. The aim of the study was the investigation of workplace bullying/mobbing-related trauma symptoms in Greek-Cypriot nurses working in emergency and critical care settings, as well as of potential correlations with demographic and occupational variables. A descriptive, cross-sectional correlational study was performed in a convenience sample of 113 nurses. A modified version of the Part B.CII of The Workplace Violence in the Health Sector-Country Case Studies Research Instrument (WVHS-CCSRI Part C.II-M) and the modified Secondary Traumatic Stress Scale (STSS-M) were used for the assessment of bullying/mobbing frequency and workplace bullying/mobbing-related trauma symptoms, respectively. A total of 46.9% of the sample reported experiences of both bullying/mobbing victimization and witnessing of bullying/mobbing to others (VWB subgroup), 21.2% reported solely bullying/mobbing victimization (SVB subgroup) and 10.6% reported witnessing of bullying/mobbing to others (SWB subgroup). A total of 22.3% did not experience or witness any bullying/mobbing at the workplace. Trauma symptoms intensity (STSS-M total score) was more severe in the participants a) with a high frequency of workplace bullying/mobbing experiences compared to those with a moderate frequency of such experiences (p = 0.018), b) of the VWB subgroup compared to those of the SWB subgroup (p = 0.019), c) employed in Emergency Departments compared to those employed in ICUs (p = 0.03), d) who had considered resigning due to bullying/mobbing experiences compared to those who had never considered resigning (p = 0.008), e) who had been punished for reporting a bullying/mobbing incident compared to those who had not (p = 0.001), and f) who considered the incident unimportant to be reported compared to those who avoided reporting due to other causes (p = 0.048). This data highlights the need to establish effective and safe procedures for bullying/mobbing reporting, aiming to support bulling/mobbing victims and witnesses, and further to protect their legal rights. Both victims and witnesses of workplace bullying/mobbing need to be assessed by mental health professionals for PTSD symptoms in order to have access to effective treatment.

The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies

AIMS

Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, and to investigate interventions countering such behaviours.

METHODS

A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database in April 2020, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to which we adhered. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were included for review.

RESULTS

Of 570 papers, 27 were eligible for inclusion. These were published between 1998 and 2020. A narrative review was performed in light of the significant heterogeneity displayed by the eligible studies. A total of 13 papers discussed the prevalence of GBSD, while 13 related to the impact of these behaviours, and six discussed mitigating strategies. GBSD was found to be common in the orthopaedic workplace, with all sources showing women to be the subjects. The impact of this includes poor workforce representation, lower salaries, and less career success, including in academia, for women in orthopaedics. Mitigating strategies in the literature are focused on providing female role models, mentors, and educational interventions.

CONCLUSION

GBSD is common in orthopaedic surgery, with a substantial impact on sufferers. A small number of mitigating strategies have been tested but these are limited in their scope. As such, the orthopaedic community is obliged to participate in more thoughtful and proactive strategies that mitigate against GBSD, by improving female recruitment and retention within the specialty.

Sexual harassment exposure and impaired mental health in medical students. The MESSIAEN national study

BACKGROUND

A previous national study has suggested that around 20% of French working women reported sexual harassment (SH) at work but we lack of data in medical students of French hospitals to guide prevention programs.

OBJECTIVES

To determine SH prevalence in a national sample of French medical students and to validate a theoretical model explaining SH causes and its impact of mental health.

METHODS

The study is a cross-sectional observational epidemiological national study. SH was defined according to the French legal definition. We further explored other discriminations and their potential association with impaired mental health in medical students. Mental health was assessed by Hamilton Anxiety & Depression scale, psychotropic drug consumption and psychotherapy follow-up. A Structured Equation Modeling was carried out to confirm our theoretical model.

RESULTS

2003 participants were recruited. SH was reported by 15.7% of the participants (19.8% of women and 5.2% of men). The SEM model showed good fit (RMSEA=0.024, CFI=0.90, TLI=0.87, WRMR=1.165). SH was associated with risk factors such as feminine gender and surgical and anesthesiology specialties. SH was also associated with exposure to discriminations based on the specialty choice and sexual orientation. SH was associated with impaired mental health.

CONCLUSION

French medical student women reported similar rates of SH than other working women, suggesting that SH prevention programs are needed in French hospitals. Surgery and anesthesiology should be targeted in priority. The prevention programs should also target other discriminations and should be evaluated in terms of potential mental health improvement.

Bullying and undermining behaviours in surgery: A qualitative study of surgical trainee experiences in the United Kingdom (UK) & Republic of Ireland (ROI)

BACKGROUND

Bullying and undermining (B/U) behaviours are documented in the international surgical workplace. This study is the largest assessment of prevalence of B/U behaviours within UK & ROI surgical training to date.

MATERIALS AND METHODS

UK & ROI surgical trainees were electronically surveyed in July 2017. The survey was open for one month and sent to all registered trainees at Core and Specialty level by the Joint Committee on Surgical Training (JCST) along with email and social media dissemination by the Association of Surgeons in Training (ASiT) and the British Orthopaedic Trainees Association (BOTA). A consensus session on the topic was conducted at the ASiT Conference in Edinburgh in March 2018. Standards for reporting of Qualitative Research were followed.

RESULTS

1412 responses were received (26.6% response rate). All training regions, grades and specialties were represented. 60% of trainees (n = 837) reported witnessing or experiencing B/U behaviours in the surgical workplace. The most common reports related to sexism; 42% (n = 568) reported witnessing or experiencing sexist language/attitudes in the workplace. This was reported more by female respondents (66% compared to 27% male). 21% (n = 291) and 13% (n = 180) reported witnessing or personally experiencing racist and homophobic language or attitudes respectively. Consultants were identified as the most frequent perpetrators. The surgical wards or theatres were the most frequently reported areas that trainees either witnessed or experienced B/U behaviours. Of those trainees who had reported a personal experience of B/U behaviours (n = 344), 20% described their experiences of reporting as negative or very negative. 48.1% of respondents felt that surgery as a whole had a moderate, high or very high degree of a concern about B/U behaviours.

CONCLUSION

B/U behaviours are prevalent in the surgical domain. Urgent action is required to eradicate this unacceptable behaviour. A cross-specialty, intercollegiate response is required to tackle this issue and improve the working culture in surgery for all.

Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology

Objective

To (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues.

Data Sources

Ovid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists.

Review Methods

A literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years.

Conclusions

Two types of hierarchies exist: “functional” and “dysfunctional.” While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety.

Implications for Practice

Otolaryngology–head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one’s own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.

Overcoming a Hostile Work and Learning Environment in Academic Surgery-Tools for Change at Every Level

Mistreatment has been documented as a negative factor in the learning environment for the past 30 y but little progress has been made to determine an effective way to significantly improve these interactions. Faculty may also be victims of a hostile work environment as well, although frequency has not been well-measured or reported. In fact, it may be difficult to identify and address mistreatment and hostility in the work place within the commonly established surgical culture. Thus, efforts to define, identify, and address workplace mistreatment or hostility are crucial to the success of the academic surgical environment. This article summarizes presentations and panel discussion that took place at the 2019 Academic Surgical Congress organized by the Association for Academic Surgery and the Society of University Surgeons. Definitions of mistreatment and hostility were provided, as well as information regarding occurrence. Tools for addressing mistreatment in the work environment and tips for creating a positive environment were presented and discussed.

ANAMT Technical Guideline (DT 07): epidemiological mapping and preventive interventions against workplace violence

Workplace violence has potentially high prevalence, in addition to positive correlation with risk of physical and mental disorders, absenteeism, high turnover rates, impaired productivity and poorer organizational climate. Workplace violence is embedded in the work routine, while its manifestations are heterogeneous and vary according to the local culture, work activities and organization. The scientific evidence for the efficacy of interventions to reduce the prevalence of violent incidents is insufficient to ground general recommendations applicable to any occupational activity. Consensus among organizational actors about notions, relevance, prevalence and risk factors associated with workplace violence, based on epidemiological mappings, is necessary, given the subjective and cultural nature of this problem, and also to enable organizational actors to jointly design pilot solutions. This approach is based on methods used in experimental studies and seeks to promote greater adherence to changes.

"Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams

BACKGROUND

Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.

METHODS AND FINDINGS

The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.

CONCLUSIONS

Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

[Response Patterns of Nursing Unit Managers regarding Workplace Bullying: A Q Methodology Approach]

PURPOSE

The purpose of this study was to identify the response patterns of nursing unit managers regarding workplace bullying.

METHODS

Q methodology was used to identify the response patterns. Thirty-six Q samples were selected from the Q population of 210 that included literature reviews and in-depth interviews with clinical nurses and nursing managers. Participants were 30 nursing unit managers who had experience managing workplace bullying and they classified the Q samples into a normal distribution frame measured on a nine-point scale. The data were analyzed using the PC-QUANL program.

RESULTS

Five types of response patterns were identified: (1) sympathetic-understanding acceleration, (2) harmonious-team approach, (3) preventive-organizational management, (4) passive observation, and (5) leading-active intervention. The preventive-organizational management type was most frequently used by the nursing unit managers.

CONCLUSION

The results of this study indicated that nursing unit managers attempted to prevent and solve workplace bullying in various ways. Therefore, it is necessary to develop and conduct leadership training and intervention programs that appropriately address the response patterns of nursing unit managers, such as those identified in this study.

Traumatized Residents - It's Not Surgery. It's Medicine

BACKGROUND

Post-traumatic stress disorder (PTSD) has been shown to be more common in surgical residents than the general population. This may be due to the rigors of a surgical residency. This study aims to compare the prevalence of screening positive for PTSD (PTSD+) among 7 medical specialties. Further, we intend to identify independent risk factors for the development of PTSD.

METHODS

A cross-sectional national survey of residents (n = 1904) was conducted from September 2016 to May 2017. Residents were screened for PTSD. Traumatic stressors were identified in those who reported symptoms of PTSD. Potential risk factors for PTSD were assessed using multivariate regression analysis with stepwise backward elimination against 30 demographic, occupational, psychological, work-life balance, and work-environment variables.

RESULTS

Residents from anesthesiology (n = 180), emergency medicine (n = 222), internal medicine (n = 473), general surgery (n = 464), obstetrics and gynecology (n = 226), psychiatry (n = 208), and surgical subspecialties (n = 131) were surveyed. No statistical difference was found in the prevalence of PTSD between specialties. Prevalence ranged from 14% to 23%. Eight independent risk factors for the development of PTSD+ were identified: higher postgraduate year, female gender, public embarrassment, emotional exhaustion, feeling unhealthy, job dissatisfaction, hostile hospital culture, and unsafe patient load.

CONCLUSIONS

The prevalence of PTSD in surgery residents was not statistically different when compared to those in other medical specialties. However, the overall prevalence of PTSD (20%) remains more than 3 times that of the general population. Overall, 8 risk factors for PTSD were identified. These risk factors varied by specialty. This may highlight the unique challenges of training in each discipline. Specialty specific interventions to improve resident wellness should be emphasized in the development of our young physicians.

Women in surgery

Where are we now?