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  • Written by Johanna Westbrook, Professor of Health Informatics and Patient Safety, Macquarie University

Bullying, harassment and other unprofessional behaviours are culturally ingrained in the Australian health-care system.

As we outline today in the Medical Journal of Australia, between one-quarter and half of doctors and nurses in Australia have been bullied, discriminated against or harassed at work.

This impacts on the way they do their work, and the quality and safety of the care they’re able to provide patients.

From doctor depression to medical errors

Workplace bullying in hospitals has been shown to cause depression, anxiety and fatigue among health workers. It can also reduce performance and levels of self-esteem.

These symptoms, along with stress and poor staff satisfaction at work, leads to higher staff absenteeism, impacting continuity of patient care and increasing the workload in already overstretched hospital clinics and wards.

Read more: You should care about your doctor's health, because it matters to yours

While we don’t have data from Australia, a survey of staff from more than 100 United States’ hospitals give us some clues about the impact. More than two-thirds (71%) of respondents – mainly nurses and doctors – agreed unprofessional behaviour and poor communication contributed to medical errors.

Worryingly, one-quarter of respondents (27%) believed unprofessional behaviour had contributed to a patient’s premature death.

Communication is compromised

Good communication among clinical teams is central to safe care. When team members feel unable to speak up due to negative consequences, care will be compromised.

One study showed medical teams who were treated rudely by an “expert observer” performed significantly worse in a simulated situation where they had to manage a sick infant compared to teams who were treated respectfully.

The teams subjected to rudeness shared less information with each other, and didn’t seek help as often. This led to poorer clinical outcomes for the patients in the simulation.

We can draw parallels with the experience of junior doctors and medical students in Australia, who report being routinely “taught by humiliation” and mistreated during clinical training rotations.

Junior doctors are regularly subjected to rudeness, hostility and aggressive questioning from their teachers. from

Junior clinicians are regularly subjected to rudeness, hostility and aggressive questioning from their teachers. These are the “expert advisors” they’re also supposed to approach for help to manage the patients in their care.

Poor outcomes for patients

Serious bullying is just the tip of the iceberg of behaviours that pose a risk to patient safety. Even more subtle unprofessional behaviours – such as passive aggression, public criticism of colleagues, or telling offensive jokes – may interfere with teamwork and the quality of patient care.

Read more: Let's stop the bullying of trainee doctors – for patients' sake

A large US study across multiple hospitals found patients’ observations of negative behaviours among surgeons could predict poor patient outcomes.

Hospitals implemented the “patient advocacy reporting system”, where patients were able to report their observations of a clinician’s behaviour while in hospital. This could be dismissing a patient’s questions, rushing them out of consultations, or being rude to other staff members in the patient’s presence.

Among a sample of more than 32,000, those patients who were operated on by surgeons who received a high number of negative patient reports in the past two years had a 14% higher rate of complications than patients whose surgeons acted professionally.

The authors suggest surgeons who are disrespectful to patients probably also behave disrespectfully towards colleagues in the operating theatre. This makes it more difficult to work with others and increases the risk of errors and poor outcomes for the patient.

Where do we go from here?

The effects of unprofessional behaviour of health workers are too great to ignore. But pronouncements of a “zero tolerance” for such behaviours are unlikely to bring about change.

Instead, we need evidence-based interventions to reduce the prevalence of negative behaviour, minimise its impact on staff and patients, and normalise a culture of safety and respect.

Read more: We don’t know enough about mental health in Australian medical students

Culture change is incredibly hard. Unfortunately, there is very limited evidence about the types of interventions which work and bring about change. We’re currently evaluating a large-scale system intervention, called Ethos, at St Vincent’s Hospitals across Australia.

The program aims to enable and empower staff to speak up when they see a problem via a confidential electronic reporting system. Trained colleagues then relay the information back to individual staff involved to encourage self-reflection and correction. Our four-year evaluation will measure how effective this program is at creating real change in behaviours.

We need more system-wide interventions to address the complex problem of bullying and harassment in our health system. But it’s important these interventions are subject to rigorous evaluations which measure both their effects on unprofessional behaviours and clinical outcomes.

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