Bullying among trainee doctors in Southern India: A questionnaire studyKL Bairy1, P Thirumalaikolundusubramanian2, G Sivagnanam3, S Saraswathi3, A Sachidananda1, A Shalini1
1 Department of Pharmacology, Kasturba Medical College, Manipal, Karnataka, India
2 Department of Medicine, Madurai Medical College, Madurai, Tamil Nadu, India
3 Faculty of Medicine and Health Sciences, Asian Institute of Medicine, Science and Technology, Sg Petani, Malaysia
Background: Workplace bullying is an important and serious issue in a healthcare setting because of its potential impact on the welfare of care-providers as well as the consumers. Aims: To gauge the extent of bullying among the medical community in India; as a subsidiary objective, to assess the personality trait of the bullying victims. Settings and Design: A cross-sectional, anonymous, self-reported questionnaire survey was undertaken among a convenient sample of all the trainee doctors at a Government Medical College in Tamil Nadu, India. Materials and Methods: A questionnaire, in English with standard written explanation of bullying was used. Basic information like age, sex, job grade and the specialty in case of Postgraduates (PGs) were also collected. Statistical Analysis: The results were subjected to descriptive statistical analysis and Chi-square test for comparison of frequencies. Results: A total of 174 doctors (115 PGs and 59 junior doctors), took part in the study with a cent percent response. Nearly half of the surveyed population reported being subjected to bullying. Nearly 54 (53%) of the men and 35 (48%) of women were subjected to bullying. Significant proportions ( P <0.0001) of medical personnel and paramedical staff bullied the PGs and junior doctors, respectively. More than 85 (90%) of bullying incidents went unreported. A significant ( P <0.0001) percentage of PGs and junior doctors revealed a personality trait towards bully. Conclusions: Workplace bullying is common among trainee doctors and usually goes unreported.
Keywords: Humans, medical students or physicians, prejudice or bullying, social behavior
Bullying is defined as a repeated pattern of aggressive behavior that escalates over time and causes victimization in the subject who is unable to defend himself or herself. It is bad for every organization and activity since it destroys teamwork, commitment and morale. Workplace bullying seems to be a universal phenomenon that cuts across several professions and the medical community is not immune to this endemic disease.,,, Studies have confirmed that there is a strong association between victimization (due to bullying) and stress, anxiety, depression and intention to leave., It is an important and serious issue because it not only adversely impacts the health of the bullied (staff) but also the quality of healthcare and patients.,
Bullying amongst junior doctors and professionals has been studied only in developed countries,,,, and has received limited, if any, attention in India and developing countries. This study was carried out to determine the prevalence of persistent and serious bullying amongst junior doctors, identify its sources and determine if any personality trait pointed towards being a "bully".
A cross-sectional questionnaire survey was conducted among junior doctors in training (compulsory rotatory resident internees; CRRIs equivalent to house officers elsewhere) and postgraduate students (PGs) of different specialties in a Government Medical College, in a metropolitan city in Tamil Nadu, India, after obtaining the approval from the institutional ethical committee. The study was carried out over a four-month period beginning January 2005. A convenient sample of 174 subjects (at any given time, approximately 1500 CRRIs and 3000 PGs serve throughout the state of Tamil Nadu) took part in the study. Standard written explanation of bullying was provided to the participants, who were advised to read it prior to filling the actual questionnaire. An anonymous questionnaire, in English, was then administered to the participants in person during their duty period and was collected immediately upon completion. The survey included four questions on bullying. The stem question, derived from one used by Hicks: "In this post, have you been subjected to persistent behavior by others which has eroded your professional confidence or self-esteem?" The analysis of differences between genders was calculated using the Chi-square test.
The questionnaire also included six selected items of a psychometric test based on Myers-Briggs type indicator to understand how the participants make decisions according to others' values and needs, so as to obtain an idea about whether they were more of thinkers or feelers. Likert type scale ranging from 'strongly agree' to 'strongly disagree' interposed with 'uncertainty' was used to elicit the responses.
On the whole, the questionnaire (Annexure 1) comprised six items pertaining to bullying, four items regarding the traits that point whether a person was a thinker or a feeler and one item regarding job satisfaction. Cronbach's alpha  was used to estimate the internal consistency of the scales and the alpha varied between 0.74 and 0.87. The results were subjected to descriptive statistical analysis and Chi-square analysis for comparison of frequencies.
One hundred and seventy-four subjects (102 males), who were approached for participation, agreed to do so. They included 59 CRRIs and 115 PGs. As shown in [Table - 1], 89 subjects reported having being bullied. The proportion of subjects bullied amongst CRRI was as high as 89%. The proportion of subjects bullied was also significantly higher amongst individuals aged below 30 years ( P <0.0001) It is pertinent to note that all the CRRIs belonged to the younger age-group category [Table - 1]. The PGs were subjected to bullying by the medical personnel ( P <0.0001; CI: 0.075-0.46), while paramedical personnel were the ones who were most frequently incriminated by the CRRIs ( P <0.0001; CI: 1.66-1.70) [Table - 2].
Irrespective of the group to which they belonged more than 85 (95%) bullying went unreported. Reports of bullying did not vary by job grade. Nearly 20 (20%) of those bullied were not sure how to complain, another 19 (20%) were afraid of the consequences, while 21 (20%) had other reasons for not complaining.
An agreement for each of the first six items [Table - 3] added to the score that one has the traits of a thinker and the higher the score one is considered as a potential bully and lower the score one is more likely to be a feeler. Upon analysis there was no significant difference between men and women with four of the six items, except with respect to two items; a) that a superior should always be tough on subordinates and b) it is not important that one should like and be liked at work. However in general, irrespective of sex both men and women scores were high pointing that the majority of them were thinkers rather than feelers.
There was no significant difference between men and women with respect to overall job satisfaction and nearly 50% of the subjects had job satisfaction.
Bullying is akin to an endemic disease that runs across borders and cultures. It is also prevalent amongst the medical community and is seen in professional, research, teaching and administrative fields. In the present study that dealt with bullying amongst junior doctors, approximately 50% of the subjects reported having being bullied, a percentage higher than that reported in a study carried out in the UK. The study suggests that bullying could be a significant problem in the country. For various reasons, bullying is generally under-reported. However, it is a matter of concern that in this study only 10% of subjects reported bullying in contrast to 67% doing so in the UK.
The comments by seniors on the failures to meet the standard of expected competence are felt as being bullied by junior colleagues. The former think they are firm but fair and the comments are an inevitable part of the relationship between trainee and trainer. The accuser feels bullied by such behavior that the accused perceives as reasonable. Such disagreements seem to be the doctors' additional dilemma, especially in a teaching institution. However, it is pertinent to note that even perceptions of bullying can have a negative impact on the overall climate and outcome of the workplace. This fact has been recently fortified by Stebbing et al , who have reported dissatisfaction with the post, wanting to change supervisors and inadequate clinical commitment of those subjected to bullying.
It has been reported that bullying others was related to aggressiveness, self-esteem and anxiety. A positive and significant relationship between depressive symptoms and bullying others was revealed for both boys and girls.
In general, in the present study, the scores pointed that "thinkers" outnumbered "feelers". In this scenario, it is possible that those who are presently being bullied could turn out to be tomorrow's bullies. At this juncture it is pertinent to mention that the results of the present study should be considered preliminary. The personality trait and the potential bully, the questionnaire in the present study was mainly based on an article by Paice and Firth-Cozens, which in turn is based on the concept of the "thinker/feeler trait".
As far as the medical profession is concerned, women remain at a risk of sexual harassment by significant others, including patients, despite the power they acquire through medical training. In India a web-based survey found that incidents of workplace-related sexual harassment do exist and the victims were mostly young and/or relatively powerless women, such as rural folk (seeking care in urban health facilities), PGs, field staff and contract employees.
The study had some inherent weaknesses: The prevalence may not be representative of the country, since the study was carried out in only one institute using a convenience sample. The method used to determine the trait of a person, as a likely potential bully has not been validated and subject to scrutiny. In addition, the study has not focused into the details of bullying, like the type, frequency of bullying. The socioeconomic status, religion and caste of the participants may have a significant bearing on the results. However, these were not elicited for social and ethical reasons.
The problem of bullying needs to be addressed in right earnest. A few measures for tackling the issue are suggested: acknowledging existence of the problem could be the starting point. Next, anti-bullying policies need to be developed, disseminated and implemented. As of now no such policies have been enunciated. Standards of behavior within the workplace, which could include a commitment on the part of employees to interact openly should be established and communicated to all employees. Information sessions could be used to increase the awareness of bullying as an organizational problem. Victims should be provided with support and access to dispute-resolution procedures., Measures like teaching the appropriate skills to those who deal with bullying, personal development of consultants or others who interact inappropriately, program for trainees to tackle bullying effectively and appropriate reward-punishment for the concerned. Developing role models would also be helpful in this regard.,
Our sincere acknowledgments are due to all the participants of the study.
[Table - 1], [Table - 2], [Table - 3]