#KnockItOut: tackling workplace bullying, harassment and undermining | Association of Anaesthetists

#KnockItOut: tackling workplace bullying, harassment and undermining

#KnockItOut – tackling workplace bullying, harassment and undermining

What is bullying?

“You must be aware of how your behaviour may influence others within and outside the team” states the GMC's good medical practice document, our professional code of conduct [1]. How we behave whilst at work affects those around us, but this may be easy to forget in the heat of the moment. Examples of unprofessional behaviours such as rudeness, incivility, belittling and humiliation are frequently found in most hospitals. 

Medicine has a traditional, hierarchical culture, and this may lead to those in positions of power misusing their status and/ or shielding such perpetrators of bad behaviour from censure. When an individual uses their positional power in a way that leaves the victim(s) feeling hurt, angry or powerless, this is bullying [2]. 

Social bullying involves unacceptable jokes related to protected characteristics (e.g. gender, race), public insults, practical jokes, slander and exploitation [3]. The line between ‘banter’ and bullying can be a fine one, and it is the perception of the victim that defines bullying, not the intention of the perpetrator [2].

Download our #Knockitout graphics

Does bullying and harassment occur in the NHS?

One fifth of NHS staff reported experiencing bullying and harassment by colleagues in last year’s NHS staff survey. Unrealistic time pressures, staffing shortages and stress were identified as factors contributing to bullying behaviour [4]. This survey looked at all NHS staff, but is this specifically a problem amongst medical staff?

The 2017 BMA survey of 7887 doctors found similar results [5, 6]. Twenty percent reported being subjected to workplace bullying or harassment, and 39% identified that bullying, harassment or undermining behaviour had occurred where they worked. This suggests that being a bystander to an incident of bullying or harassment is common amongst doctors. The survey found bullying affects consultants and trainees fairly equally, with disabled, LGBT and BAME doctors reporting higher levels. When asked, “Why do you think there is or may be a problem with bullying in the NHS?” familiar themes included staff under pressure, difficulty in challenging poor behaviours from seniors, and a lack of management commitment to tackling bullying. 

A lack of clarity as to what is acceptable behaviour, and a lack of clear reporting procedures, were also felt to contribute. More recently the incidence of bullying amongst non-training grade doctors has been highlighted, with 30% of SAS doctors and 23% of locally-employed doctors reporting they had been bullied, undermined or harassed at work in the last year [7]. Rudeness, incivility, belittling and humiliation were the most common types of undermining behaviour reported. When bullying relating to protected characteristics was reported, race was the most commonly cited factor.

Do we have a problem with bullying and unprofessional behaviours in anaesthesia?

Specialty specific data is surprisingly difficult to come by. The most recent GMC national training survey that had a specialty breakdown of bullying and harassment was in 2017 [8], reporting that 4.6% of anaesthesia trainees described experiencing, or witnessing, bullying and harassment at work. This is a lower incidence than that reported by our surgical trainee colleagues, where 8% of surgical respondents and 11.2% of obstetrics and gynaecology respondents reported being victims of, or witnessing, bullying and harassment. While it may not be an overwhelming problem in anaesthesia, it is plausible that we are frequent observers of bullying and undermining in other staff groups through our multi-disciplinary working environment in theatres and on the labour ward. We are working with the psychology research team at Northumbria University on a project to study trainee anaesthetists’ experiences of witnessing workplace bullying to investigate this further.

What are the effects of bullying in healthcare?

Research has demonstrated that merely witnessing incivility and unprofessional behaviours can cause a performance decrease of 20%, and worryingly this incivility can spread, with witnesses being less helpful to others even if they are unconnected to the event [9]. Exposure to bullying, either as a victim or bystander, is also associated with negative job-related and health- and wellbeing-related outcomes. There is an increase in mental and physical health problems, symptoms of PTSD, burnout, increased intention to leave the organisation, reduced job satisfaction, and organisational commitment. Workplace bullying is also associated with employee absenteeism, negative performance self-perception, and poor sleep [10].

There are serious effects on patients too; in NHS organisations where staff surveys report bullying, patients are less likely to report being treated with dignity and respect [11]. There is a strong association between bullying and the occurrence of adverse events and compromised patient safety [12]. Indeed, in his public inquiry into the failings at Mid-Staffordshire, Robert Francis QC wrote; 

“The common culture of caring requires a displacement of a culture of fear with a culture of openness, honesty and transparency, where the only fear is the failure to uphold the fundamental standards and the caring culture” [13]. 

Going beyond the individual health and wellbeing, the financial cost of bullying is huge. These can be measured in terms of sickness absence, employee turnover, diminished productivity, sickness presenteeism, compensation, litigation and industrial relations. A conservative estimate of the cost of bullying to the NHS is £2.28 billion per year [14].

SAFER space infographic 

Civility poster 


Through our #KnockItOut campaign, we want to change our workplace culture to one that is free from bullying, harassment and undermining behaviours. Whilst we endeavour to create a compassionate culture, we need all our staff members to be able to respond in constructive ways when they witness unprofessional behaviour. We want to give them the tools to confidently and successfully challenge these behaviours when they see them. The active bystander approach has been used in several anti-bullying and anti-sexual harassment campaigns [15] – see Figure 1 for our version. Providing bystanders to an incident with a framework to intervene safely is an important part of changing the culture around bullying.

Download our #Knockitout graphics

Being witness to a bullying incident can be frightening or unsettling. There are times when reacting immediately may involve being dragged into an argument, or cause further unproductive behaviours. Taking a brief pause, recognising the situation, responding constructively, and aiming for a measured approach can help defuse the incident. We recognise that ‘one size does not fit all’ in difficult situations, and aim to provide a range of options to enable staff to intervene where appropriate. 

We also recognise that one’s place in the organisational hierarchy may alter how able one feels to challenge poor behaviours; a junior staff member may well feel more able to delegate to a trusted senior colleague in, or after, the moment. The environments that we work in are increasingly stressful places, making negative and unprofessional behaviours more likely. Sometimesdeclaring that you are aware of the situation, "I notice you are a bit stressed, what can we do to help?", will allow the person under stress to ask for quiet, or perhaps assistance. An indirect intervention by distraction can be useful to change the focus of the interaction, and to refocus on the task at hand. Finally, the situation may not be suitable to be addressed in the moment; in certain circumstances a delay may be required. 

Once the stressful situation has settled, speak to the person who was inappropriate, stick to the facts as they happened, and highlight how their words or actions were perceived by others. In addition to providing intervention strategies, we want to encourage a ‘SAFER’ space at work, where kindness and civility are paramount, and staff work together towards a shared goal. This can include engaging the team in a verbal run through of likely stressful points in the day and how best to respond “When we get to the anastomosis can we turn the music off and have quiet in theatre, please”  or “I’m expecting a challenging airway, so can we not be interrupted during the intubation process, please” (Figure 2).

The Association of Anaesthetists is a member of the NHS anti-bullying alliance, and by working together with the other organisations involved we want to tackle the cultural and systemic issues that contribute to bullying. It is time for us to demonstrate as a profession that we are committed to change and we will not tolerate unprofessional behaviour: it is time for anaesthesia to #KnockItOut.

Roopa McCrossan 
Association of Anaesthetists Trainee Committee
Locum Consultant in Anaesthesia, Freeman Hospital; Newcastle

Karen Stacey 
Elected member, Association of Anaesthetists Trainee Committee
Locum Consultant Anaesthetist, Imperial College Healthcare NHS Trust

Twitter: @RooMcCrossan@karenstacey82


  1. General Medical Council. Good medical practice, 2019. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice (accessed 12/7/2020). 
  2. Royal College of Surgeons of England. Avoiding unconscious bias: a guide for surgeons, 2016. https://www.rcseng.ac.uk/library-andpublications/ rcs-publications/docs/avoiding-unconscious-bias/ (accessed 12/7/2020). 
  3. The Joint Commission, Division of Healthcare Improvement. Bullying has no place in health care, 2016. https://www. jointcommission.org/-/media/deprecated-unorganized/importedassets/ tjc/system-folders/joint-commission-online/quick_safety_ issue_24_june_2016pdf.pdf?db=web&hash=84E4112AB428AD3C A1D5B9F868A1AD10 (accessed 12/7/2020). 
  4. NHS England. NHS staff survey 2019. National results briefing, 2020. https://www.nhsstaffsurveys.com/Caches/Files/ST19_National%20 briefing_FINAL%20V2.pdf (accessed 12/7/2020). 
  5. British Medical Association. Addressing bullying and harassment of doctors in the workplace and promoting dignity at work, 2018. https://www.bma.org.uk/media/1117/bma_bullying_and_ harassment_poster_oct_2019.pdf (accessed 12/7/2020). 
  6. The Guardian. A fifth of NHS doctors were bullied or abused last year, study finds, 2018. https://www.theguardian.com/society/2018/ nov/01/nhs-doctors-bullying-abuse-bma-survey (accessed 12/7/2020). 
  7. General Medical Council. Specialty, associate specialist and locally employed doctors workplace experiences survey: initial findings report, 2020. https://www.gmc-uk.org/-/media/documents/sas-andle- doctors-survey-initial-findings-report-060120_pdf-81152021.pdf (accessed 20/6/2020) 
  8. General Medical Council. Training environments 2017: key findings from the national training survey, 2017. https://www. gmc-uk.org/about/what-we-do-and-why/data-and-research/-/ media/documents/nts-report-20173_pdf-72689147.pdf (accessed 12/7/2020). 
  9. Porath C, Pearson C. The price of incivility. Harvard Business Review 2013; 91: 114-21. 
  10. Nielsen MB, Einarsen S. Outcomes of exposure to workplace bullying: a meta-analytic review. Work and Stress 2012; 26: 309-32. 
  11. Publishing service Gov.UK. NHS staff management and health service quality, 2011. https://assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/ file/215454/dh_129658.pdf (accessed 12/7/2020). 
  12. Rosenstein AH. The quality and economic impact of disruptive behaviours on clinical outcomes of patient care. American Journal of Medical Quality 2011; 26: 372-9. 
  13. Gov.UK. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013. https://www.gov.uk/government/publications/ report-of-the-mid-staffordshire-nhs-foundation-trust-public-inquiry (accessed 12/7/2020). 
  14. Kline R, Lewis D. The price of fear: estimating the cost of workplace bullying and harassment to the NHS in England. Public Money & Management 2019; 39: 166-74. 
  15. Coker AL, Cook-Craig PG, Williams CM, et al. Evaluation of Green Dot: an active bystander intervention to reduce sexual violence on college campuses. Violence Against Women 2011; 17: 777-96.