Bullying and Sexual Discrimination in the Greek Health Care System

A gender-based review of workplace violence amongst the global health workforce-A scoping review of the literature

Workplace violence (WPV) impacts all levels of the health workforce, including the individual provider, organization, and society. While there is a substantial body of literature on various aspects of WPV against the health workforce, gender-based WPV (GB-WPV) has received less attention. Violence in both the workplace and broader society is rooted in gendered socio-economic, cultural, and institutional factors. Developing a robust understanding of GB-WPV is crucial to explore the differing experiences, responses, and outcomes of GB-WPV with respect to gender. We conducted a scoping review and report on the prevalence and risk factors of GB-WPV in healthcare settings globally. The review followed the Preferred Reporting Items for Systematic and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). We registered the scoping review protocol on the Open Science Framework on January 14, 2022, at https://osf.io/t4pfb/. A systematic search was conducted of empirical literature in five health and social science databases. Of 13667, 226 studies were included in the analysis. Across the studies, more women than men experienced non-physical violence, including verbal abuse, sexual harassment, and bullying. Men experienced more physical violence compared to women. Younger age, less experience, shifting duties, specific clinical settings, lower professional status, organizational hierarchy, and minority status were found to be sensitive to gender, reflecting women's structural disadvantages in the workplace. Given the high prevalence and impact of GB-WPV on women, we provided recommendations to address systemic issues in clinical practice, academia, policy, and research.

International Cross-Sectional Survey of Bullying, Undermining, and Harassment in the Vascular Workplace

OBJECTIVE

Bullying, undermining behaviour, and harassment (BUH) may exist in healthcare settings, impacting on patient care. The aim of this international study was to evaluate the characteristics of BUH experienced by physicians treating vascular diseases at various career stages.

METHODS

This was an anonymous international structured non-validated cross-sectional survey distributed via relevant professional societies in collaboration with the Research Collaborative in Peripheral Artery Disease. The survey was disseminated through societies' newsletters, emails, and social media. Data were collected online, allowing free text entries alongside structured multiple choice questions based on previous surveys. Demographics, geographical information, and data relating to stage and training environment were collected.

RESULTS

Of 587 respondents from 28 countries, 86% were working in vascular surgery, mostly at a university hospital (56%); 81% were aged between 31 and 60 years, 57% were working as a consultant, and 23% as a resident. Respondents were mostly white (83%), male (63%), heterosexual (94%), and without disability (96%). Overall, 253 (43%) reported experiencing BUH personally, 75% had witnessed BUH toward colleagues, and 51% witnessed these in the last 12 months. Female sex and non-white ethnicity were associated with BUH (53% vs. 38% and 57% vs. 40% respectively; p < .001 in both cases). While working as a consultant, 171 (50%) reported experiencing BUH, more often among females, non-heterosexuals, those who were not working in their country of birth, and non-white people. Specialty and hospital type were not associated with BUH.

CONCLUSION

BUH remains a major problem in the vascular workplace. Female sex, non-heterosexuality, and non-white ethnicity are associated with BUH at various career stages.

Experiences and Perceptions of Racism and Sexism Among Alberta Physicians: Quantitative Results and Framework Analysis of a Cross-Sectional Survey

BACKGROUND

The prevalence of harassment and discrimination in medicine differs by race and gender. The current evidence is limited by a lack of intersectional analysis.

OBJECTIVE

To evaluate the experiences and perceptions of harassment and discrimination in medicine across physicians stratified by self-identified race and gender identity.

DESIGN

Quantitative and framework analysis of results from a cross-sectional survey study.

PARTICIPANTS

Practicing physicians in the province of Alberta, Canada (n=11,688).

MAIN MEASURES

Participants completed an instrument adapted from the Culture Conducive to Women's Academic Success to capture the perceived culture toward self-identified racial minority physicians (Black, Indigenous, and People of Color (BIPOC)), indicated their perception of gender inequity in medicine using Likert responses to questions about common experiences, and were asked about experiences of reporting harassment or discrimination. Participants were also able to provide open text comments.

KEY RESULTS

Among the 1087 respondents (9.3% response rate), 73.5% reported experiencing workplace harassment or discrimination. These experiences were least common among White cisgender men and most common among BIPOC cisgender women (52.4% and 85.4% respectively, p<0.00001). Cisgender men perceived greater gender equity than cisgender women physicians, and White cisgender men physicians perceived greatest racial equity. Participant groups reporting the greatest prevalence of harassment and discrimination experiences were the least likely to know where to report harassment, and less than a quarter of physicians (23.8%) who had reported harassment or discrimination were satisfied with the outcome. Framework analysis of open text responses identified key types of barriers to addressing racism, including denial of racism and greater concern about other forms of discrimination and harassment.

CONCLUSIONS

Our results document the prevalence of harassment and discrimination by intersectional identities of race and gender. Incongruent perceptions and experiences may act as a barrier to preventing and addressing harassment and discrimination in the Canadian medical workplace.

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.

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.

Systematic review of academic bullying in medical settings: dynamics and consequences

PURPOSE

To characterise the dynamics and consequences of bullying in academic medical settings, report factors that promote academic bullying and describe potential interventions.

DESIGN

Systematic review.

DATA SOURCES

We searched EMBASE and PsycINFO for articles published between 1 January 1999 and 7 February 2021.

STUDY SELECTION

We included studies conducted in academic medical settings in which victims were consultants or trainees. Studies had to describe bullying behaviours; the perpetrators or victims; barriers or facilitators; impact or interventions. Data were assessed independently by two reviewers.

RESULTS

We included 68 studies representing 82 349 respondents. Studies described academic bullying as the abuse of authority that impeded the education or career of the victim through punishing behaviours that included overwork, destabilisation and isolation in academic settings. Among 35 779 individuals who responded about bullying patterns in 28 studies, the most commonly described (38.2% respondents) was overwork. Among 24 894 individuals in 33 studies who reported the impact, the most common was psychological distress (39.1% respondents). Consultants were the most common bullies identified (53.6% of 15 868 respondents in 31 studies). Among demographic groups, men were identified as the most common perpetrators (67.2% of 4722 respondents in 5 studies) and women the most common victims (56.2% of 15 246 respondents in 27 studies). Only a minority of victims (28.9% of 9410 victims in 25 studies) reported the bullying, and most (57.5%) did not perceive a positive outcome. Facilitators of bullying included lack of enforcement of institutional policies (reported in 13 studies), hierarchical power structures (7 studies) and normalisation of bullying (10 studies). Studies testing the effectiveness of anti-bullying interventions had a high risk of bias.

CONCLUSIONS

Academic bullying commonly involved overwork, had a negative impact on well-being and was not typically reported. Perpetrators were most commonly consultants and men across career stages, and victims were commonly women. Methodologically robust trials of anti-bullying interventions are needed.

LIMITATIONS

Most studies (40 of 68) had at least a moderate risk of bias. All interventions were tested in uncontrolled before-after studies.

A Report of Gender Bias and Sexual Harassment in Current Plastic Surgery Training: A National Survey

BACKGROUND

Gender bias and sexual misconduct continue to pervade medicine. The authors hypothesize that gender bias and sexual misconduct disproportionately and negatively affect female plastic surgery trainees.

METHODS

A national survey of plastic surgery trainees (2018 to 2019) was conducted using previously validated sexual harassment surveys adapted for relevance to plastic surgery. Respondents were queried about experiences with workplace gender bias and harassment; personal and professional impact; and reporting practices. Analyses included chi-square, logistic regression, and analysis of variance. Significance was accepted for values of p < 0.05.

RESULTS

There were 236 responses (115 female respondents; 20.1 percent response rate). Most respondents were Caucasian (Asian/Pacific Islander, n = 34) residents (n = 123). The feeling of hindrance to career advancement was greater for women, by 10-fold (p < 0.001), and increased with age (p = 0.046). Women felt uncomfortable challenging attitudes regarding gender inequality (p < 0.001), regardless of training levels (p = 0.670) or race (p = 0.300). Gender bias diminished female trainees' career goals/ambition (p < 0.001). Women were more likely to experience sexual harassment, in the form of jokes (p = 0.003) and comments about their body or sexuality (p = 0.014). Respondents reported the majority of perpetrators of harassment to be attending physicians (30 percent) and other trainees (37 percent). Most common reasons to not report incidents included "futility" (29 percent) and "fear" (20 percent). Women experienced at least three symptoms of depression/anxiety, significantly higher than men (p = 0.001).

CONCLUSIONS

Gender bias and sexual misconduct negatively affect female trainees' attitudes toward their career. Two-thirds of cases of sexual harassment originate from other physicians. Minority trainees are less prepared to address transgressions and more likely to experience sexual coercion. Trainees perceive a culture nonconducive to reporting. These findings can guide changes and discussions surrounding workplace culture in plastic surgery training.

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.

Discrimination, Bullying and Harassment in Surgery: A Systematic Review and Meta-analysis

BACKGROUND

In 2015, the public media in Australia reported a series of life stories of victims who had been subjected to inappropriate behaviors in their surgical careers, bringing the profession into disrepute. Currently, limited data are available in the medical literature on discrimination, bullying and harassment (DBH) in surgery. This significant information gap prompted a systematic review to compile relevant information about DBH in surgical practice and training, in particular, its prevalence and impact.

METHODS

A literature search was conducted using the MEDLINE, EMBASE and PubMed databases (May 1929-October 2017). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Eight studies, comprising 5934 participants, were examined. Discrimination occurred in a pooled estimate of 22.4% [95% Confidence Interval (CI) = 14.0-33.9%]. One of the papers reported the prevalence of bullying using two methods including Revised Negative Acts Questionnaire and a definition by Einarsen. Pooled estimate of incidence rate was thus 37.7% (95% CI = 34.0-41.5%) and 40.3% (95% CI = 34.7-46.2%), respectively. In terms of harassment, pooled prevalence was 31.2% (95% CI = 10.0-65.0%).

CONCLUSIONS

DBH is a significant issue in surgery. The true incidence of these issues may remain underestimated. Actions are being taken by professional bodies to create a positive culture in surgery. The effectiveness of these strategies is yet to be determined. More studies are warranted to investigate the magnitude of these issues given their psychological impact, and more importantly to monitor the effectiveness of current measures.

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

Background

Bullying, undermining behaviour and harassment (BUBH) have been reported in entertainment, politics and sport. Such behaviours may also be common in surgery, and are frequently associated with poor patient care and inferior outcomes. The aim was to define the prevalence and impact of this behaviour in the international surgical workplace, and to explore counterstrategies.

Methods

A systematic review was conducted by searching EMBASE, Medline, PsycINFO and the Cochrane Database of Systematic Reviews in August 2017. Original research studies (Oxford Centre for Evidence-based Medicine levels 1–4) investigating the prevalence and impact of BUBH in surgery, and/or counterstrategies, were eligible for inclusion. The review was conducted in accordance with PRISMA guidelines.

Results

Of 2692 papers, 32 were eligible for inclusion. Twenty-two reported the prevalence of BUBH in surgery, 11 studied the impact of this behaviour and six investigated counterstrategies. Prevalence data showed that BUBH are common in the surgical workplace. Their impact can be profound, compromising mental health, reducing job satisfaction, and inducing suicidal ideation. Formal reporting systems were perceived as ineffective and even potentially harmful to victims.

Conclusion

Bullying, undermining behaviour and harassment are highly prevalent within surgery, and extremely damaging to victims. There is little high-quality research into counterstrategies, although professionalism training using simulated scenarios may be useful.