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Exploring Medical ’ Perceptions and Experiences of Amongst Hospital-Based Doctors

Caroline Lambert ORCID: orcid.org/0000-0002-5442-711X

Submitted in total fulfilment of the requirements of the degree of Doctor of

October 2017

Department of Social School of Sciences Faculty of Medicine, Dentistry & Health Sciences The of Melbourne

Abstract

Historically, in Australia, the topic of bullying amongst doctors has been investigated sporadically. This has recently changed with an increase in research being conducted. However, the focus of this research is often on measuring and establishing the prevalence and impact of , and is sometimes limited to a specialty, such as surgery, or a particular behaviour such as academic . Furthermore, both nationally and internationally, the settings for many investigations are educational rather than practice ones. Much research on medical students, and abrasive, bullying behaviours, focuses on gauging prevalence and impact, and often labels these behaviours as something other than bullying. To date, medical perceptions and experiences of these bullying behaviours amongst hospital-based doctors have been overlooked. The aim of this study was to extend the current understanding of medical students’ perceptions and experiences of bullying amongst hospital-based doctors. To achieve this aim, the research centred on three core questions, asking how medical students perceived and experienced bullying amongst hospital-based doctors, and how power and dynamics might contribute, or extend, the current discourse on bullying and medical student insights and experiences. The sample targeted in the research were medical students who attended one of the medical schools in the State of Victoria, Australia. The participants did not necessarily need to identify as having experienced or witnessed bullying, rather was based on having insights on hostile or abrasive behaviours amongst hospital-based doctors, therefore based on having some clinical experience within a hospital setting. The research design was qualitative in nature. Sixteen medical students participated in semi-structured interviews. The findings of this study provide an expanded understanding of how medical students perceive and experience bullying amongst hospital-based doctors. New knowledge identifies that using theories, and an associated of oppression, may assist in understanding further why some medical students report using criteria to define bullying behaviours that is different from that found in policies or legislation. In addition, these theories may explain why medical students will not report bullying behaviours even if they have experienced or witnessed the negative impact of it. Models

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of oppression can also assist in illuminating why some medical students suggested that bullying behaviours amongst doctors were inevitable or even, at times, reasonable. The individualistic focus of existing studies was also identified as a key issue. Medical students’ inability to explain contextual factors. and dynamics inherent to much bullying amongst doctors was also noted. This study has generated a number of implications for medical and further research, including the observation that disciplines outside medicine may have unique potential for powerful contributions to the current conversation. The research confirms the complexity of the issue, and establishes the need to keep the subject of amongst doctors firmly on the agenda.

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Declaration

This is to certify that: i. the comprises only my original work toward the PhD ii. due acknowledgment has been made in the text to all other material used iii. the thesis is less than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices.

Signed:

Caroline Lambert

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Preface

Professional editors Dr Haydie Gooder & Dr Gillian Dite provided reference proofreading and document formatting services according to standards D and E of the Australian Standards for Editing Practice and the Guidelines for Editing Research Theses from the Institute of Professional Editors.

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Acknowledgments

Thank you to the University of Melbourne, the Department of Social Work, and my very Lou Harms and Dr David Rose. Lou, you are the very embodiment of all that is virtuous in academic supervision, and I am eternally grateful for your wisdom, patience and professionalism. Thank you to Professor Lynn Gillam and Professor Geoff McColl for your invaluable input. Thank you to the contributions and conversations of the medical students who were courageous enough to share their stories with me. Without your generosity, giving both your time and insights, there would be no research. To my beautiful boys, James and Gilbert, this is actual proof that anyone can do anything - when they don’t give up. Andrew, I am enormously grateful for your never- ending support in my never-ending quest to know more. This thesis has been made possible, due to the superb support of a ratbaggery of animals, Possy, Boots, Leonard and Lily. Finally, much gratitude to Mum and Dad, for having such a lovely, unwavering faith in my ability. It’s finally done.

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Table of contents

Abstract ...... i Declaration ...... iii Preface ...... iv Acknowledgments ...... v List of figures ...... xi List of tables ...... xii Chapter 1. The perfect storm: A convergence of elements, creating a context ripe for investigation ...... 1 1.1. Fundamental elements of the research ...... 3 Research aim ...... 3 Research aim and researcher reflexivity ...... 3 Key areas investigated ...... 4 Research questions...... 7 Research overview ...... 7 1.2. Medical students...... 7 Medical in Victoria ...... 9 1.3. Outline of the thesis ...... 10 Part one ...... 10 Part two ...... 11 Chapter 2. What is workplace bullying? ...... 12 2.1. The tension of subjectivity and objectivity ...... 12 2.2. Core criteria for workplace bullying ...... 15 Negative impact ...... 16 Repeated behaviours ...... 16 Duration and systematic ...... 18 Power differential ...... 18 Targets of bullying label themselves as having been bullied...... 19 2.3. Why is it important to define the term ‘bullying’? ...... 19 2.4. Prevalence of workplace bullying ...... 20 Bullying in healthcare ...... 21 Bullying in the education sector ...... 25

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Bullying within the legal system ...... 27 2.5. Consequences of workplace bullying ...... 28 Negative effects of workplace bullying ...... 28 Organisational effects of workplace bullying ...... 30 Impact of workplace bullying on the medical ...... 30 2.6. Can bullying serve a purpose, or have a positive impact? ...... 31 2.7. Chapter summary ...... 32 Chapter 3. Context and multi-causality of workplace bullying ...... 33 3.1. Organisational contribution to workplace bullying ...... 34 3.2. or task contribution to workplace bullying ...... 35 3.3. Communication in medicine ...... 39 3.4. The intergenerational legacy of bullying behaviours ...... 41 3.5. The contribution of medical and enculturation processes to workplace bullying ...... 42 3.6. Professional and organisational guidelines and codes of conduct ...... 44 Professional codes ...... 45 Organisational codes relating to bullying and in hospitals ...... 48 3.7. Broader economic contribution ...... 49 3.8. influence on bullying and the medical profession ...... 50 3.9. Media influence on bullying and the medical profession ...... 51 3.10. Australian parliamentary findings, legislation and regulatory considerations ...... 53 Parliamentary investigations ...... 53 Australian legislation ...... 54 3.11. Individual contribution to workplace bullying ...... 57 Biology of targets ...... 58 Age and experience of workplace bullying targets ...... 60 3.12. Individual contribution to bullying: Who bullies? ...... 61 3.13. Perceptions of individual contribution to bullying...... 62 3.14. Perceptions of environmental influence contribution to bullying ...... 63 3.15. Summary of methods in current relatable workplace bullying literature ...... 64 3.16. Gaps and limitations in current knowledge of workplace bullying & medical students ...... 67 3.17. Summary of identified influences of workplace bullying ...... 67 3.18. Chapter summary ...... 68

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Chapter 4. Bullying in medicine and dynamics of power and oppression ...... 70 4.1. Language choice: How bullying behaviours are sometimes defined as something else ...... 71 4.2. Medical students perceptions on power, oppression, hierarchy and bullying ...... 74 4.3. The connections between power, organisational hierarchy, bullying and development of a workplace culture ...... 75 Workplace bullying and oppression ...... 80 4.4 Chapter summary ...... 83 Chapter 5. Research design ...... 85 5.1. ...... 85 Research design ...... 85 Ethical considerations ...... 91 5.2. Methods ...... 95 Target group ...... 95 Research instrument...... 99 Hypothetic case scenario ...... 106 Data analysis ...... 108 5.3. Chapter summary ...... 113 Chapter 6. Introducing the research participants ...... 115 6.1. Demographic profile of participants ...... 115 The participants as a ...... 116 6.2. Conceptualisations of hierarchy ...... 118 Perceived organisational rank ...... 119 Perceived professional hierarchy ...... 120 What is in a name: The vexatious issue of professional ...... 122 6.3. Chapter summary ...... 125 Chapter 7. Perceptions of bullying ...... 126 7.1. Perceptions of the intergenerational nature of bullying ...... 126 7.2. Conceptualisations of the causes of bullying behaviours ...... 132 7.3. Conceptualisations of within medicine ...... 141 7.4. The hypothetical ...... 142 7.5. Conceptualisations of prevalence of bullying ...... 143 7.6. Definition: What is bullying? Including individual, organisational, professional, and broader influences ...... 144

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7.7. Beliefs on the impact of bullying ...... 149 7.8. Conceptualisations of better alternatives ...... 157 7.9. Chapter summary ...... 158 Chapter 8. Experienced behaviours and the context in which they occur ...... 160 8.1. Behavioural interactions...... 160 Described experiences of abrasive incidences ...... 162 8.2. Communication patterns amongst doctors ...... 164 8.3. Teaching and mentoring ...... 168 8.4. Described incidents of sexism and sexual ...... 170 8.5. Described impact of abrasive incidences ...... 172 8.6. Context ...... 174 Knowledge of organisational policies ...... 175 The medical profession ...... 176 Cultural silos ...... 181 8.7. Chapter summary ...... 187 Chapter 9. Discussion ...... 188 9.1 Beliefs on bullying behaviours in the practice of medicine ...... 188 9.2 The good, the bad and the ugly: behaviours experienced by medical students ...... 196 9.3. Context of bullying: The medical profession and cultural silos ...... 202 The medical profession ...... 203 Cultural silos ...... 204 9.4. Implications ...... 206 Implications for ...... 206 Implications for further research ...... 208 Theoretical contribution...... 209 9.5. Strengths and limitations ...... 209 Strengths ...... 209 Limitations ...... 211 9.6. Conclusions ...... 212 References ...... 216 Appendices ...... 240 Appendix 1. Research journal ...... 240 Sample #1 ...... 240

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Sample #2 ...... 241 Appendix 2. Field notes sample ...... 242 Appendix 3. Correspondence on ethics committee approval ...... 243 Appendix 4. document for participant interviews ...... 245 Appendix 5. Plain language statement ...... 246 Appendix 6. Recruitment flyers ...... 248 UoM Learning System email ...... 248 Recruitment flyer sample #2 ...... 249 Appendix 7. Letter to a recruitment gatekeeper ...... 250 Appendix 8. Interview guides ...... 251 Sample #1 ...... 251 Sample #2 ...... 255 Appendix 9. Demographic Questions List ...... 259

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List of figures

Figure 3.1. Hospital staff memorandum of bullying and media ...... 53 Figure 3.2. Options for a Victorian workplace bullying claim ...... 56 Figure 3.3. Gaps and limitations in current knowledge of workplace bullying (WPB) and medical students ...... 67 Figure 3.4. Contributing factors to workplace bullying amongst doctors...... 68 Figure 4.1. Relationships between oppression, bullying and medical student perception ...... 83 Figure 5.1. Potential risks vs. benefit ...... 94 Figure 5.2. Evaluating quality exercise ...... 99 Figure 5.3. Flowchart of data collection process ...... 101 Figure 5.4. Table of data analysis phases ...... 109 Figure 5.5. Extract from phase two of data analysis ...... 111 Figure 5.6. Codes refined into themes ...... 113 Figure 7.1 Participant diagram on ‘medical workplace bullying’ ...... 139 Figure 7.2. Hypothetical case scenario ...... 142

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List of tables

Table 6.1. Participant demographics ...... 116

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Chapter 1. The perfect storm: A convergence of elements, creating a context ripe for investigation

Workplace bullying amongst medical doctors is understood to occur at high levels within Australian hospitals. This understanding is derived from numerous prevalence studies, and is consistent with the levels of bullying or measured amongst in hospitals internationally. Although studies have tended to use other terms to describe bullying behaviours amongst, and of, medical students, there is considerable research which indicates that medical students and trainee doctors are often present during abrasive interactions amongst doctors (Cook, Vineet, Rasinski, Curlin & Yoon, 2014; Fnais et al., 2014; Scott, Caldwell, Barnes & Barrett, 2015; Commonwealth of Australia, 2016). While prevalence is further discussed in Chapter Two, it is the increasing evidence documenting the existence of, and levels of, bullying amongst doctors, combined with having witnessed abrasive behaviours amongst doctors in my clinical practice as a hospital social worker, which sparks initial interest in the topic. The well-recognised negative effects on both organisations and involved in incidences of workplace bullying, combined with the lack of lived experience studies, contributes to a sense that this is a phenomenon which is ripe for further investigations (Hogh, Mikkelsen & Hansen, 2011; Commonwealth of Australia, 2012). Furthermore, after preliminary exploration of the literature, it is also noted that bullying specifically within a healthcare setting means that the negative impact has potential to extend to the patient (Rosenstein, 2011; Ivory, 2015). The broader community context, in which this research is conducted, has shifted dramatically over the study’s time frame, with very few investigations initially being recorded. However, while bullying in medicine has not always been a topic that has received focused consideration either from within the profession or the wider community, in the current Australian context, over the past several years bullying and harassment amongst doctors has gained widespread attention from the media. In turn, that attention has led to increased community awareness of the issue and an upsurge in investigative inquiries and reports from professional and political bodies alike. Within Australia, specifically Victoria, increasing levels of media attention can be traced back to a 2005 Victorian Civil and Administrative Tribunal verdict to uphold a

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decision by then trainee, female neurosurgeon Caroline Tan (Hannan, 2008). Since that time a small but steady stream of newsprint articles outlining individual cases of harassment, bullying or discrimination against doctors have been published (media representation and bullying is discussed further in Chapter Three). Nevertheless, it was not until 2015 when controversial comments by senior surgeon Gabrielle McMullan caught the attention of the media, that a nationwide focus on harassing, discriminating and bullying behaviours amongst doctors was reignited (Medew, 2015b). However, this time around the widespread media attention prompted the Royal Australasian of Surgeons (RACS) to form an Expert Advisory Committee (EAC) on bullying and harassment in medicine, which resulted in a flow on effect of government funded reports and medical professional bodies updating or generating new policies, and codes surrounding these abrasive behaviours. In 2016 a parliamentary Senate inquiry, under the authority of the Community References Committee investigated and reported on bullying and harassment in the Australian medical profession. The number one recommendation from the Senate report is that “all parties with responsibility for addressing bullying and harassment in the medical profession, including governments, hospitals, specialty and : • acknowledge that bullying and harassment remains prevalent within the profession, to the detriment of individual practitioners and patients alike; • recognise that working together and addressing these issues in a collaborative way is the only solution; • commit to ongoing and sustained action and resources to eliminate these behaviours” (Commonwealth of Australia, 2016, ix)

With the Senate mandate in , the focus of this thesis is to explore and understand better, how medical students might perceive and experience workplace bullying amongst their qualified hospital-based colleagues. While there are multiplicities of individual, and environmental factors that contribute to an initial incident of workplace bullying, there are also a number of elements that contribute to the perpetuation or maintenance of abusive behaviours in a workplace. Current research indicates a strong link between environmental context and workplace bullying (Salin, 2003; Baillien, Neyens, Dewitte & De Cuper 2009; Magee et al., 2014), consequently this study centres on the connection between professional and organisational influence, and medical student perceptions and experience of workplace bullying. Additionally, what remains

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evident throughout all the relatable literature, the anecdotal stories and the media accounts of bullying in medicine, is the ubiquitous presence of power dynamics, either in the form of , disparity or other oppressive elements. Section 1.1 unpacks the core components of this research in greater detail.

1.1. Fundamental elements of the research

This section introduces the key components of the research including aims, initial researcher assumptions and genesis for the study, key areas of investigation and central research questions.

Research aim

The central aim of the study is: • To gain an enhanced understanding of medical students’ perceptions, and experiences of workplace bullying amongst hospital-based doctors.

Research aim and researcher reflexivity

The above aim has developed progressively from my initial interest in the workplace bullying observed amongst doctors whilst working as a social worker in large public teaching hospitals. Having witnessed senior doctors humiliate junior medical staff on ward rounds, and in unit meetings, and listened while doctors spoke privately of the , and powerlessness they felt as the result of these incidents, it became clear that there were dynamics and interactions occurring amongst doctors that were frequent and potentially harmful to all those involved. At the time of my clinical practice I was unaware of bullying behaviour amongst the social workers, which is not to suggest that it did not exist, but rather, I was simply ignorant to it, which speaks perhaps to the power of enculturation and becoming desensitised to certain behaviours, norms, values and processes. Early in the research process it became apparent that there is a strength and clarity of investigative lens when exploring a phenomenon, such as workplace bullying, occurring within a disciplinary context other than your own. I acknowledge, and am reflexive of the fact that my own professional background is central to the research process, and that my personal values of equality, non- maleficence, justice and fairness have further influenced the decision to focus on

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researching medical students perceptions and experiences of bullying amongst hospital- based doctors. Subsequent research for a Masters of Health Ethics, which explores black humour use by doctors, led to literature indicating that workplace bullying is indeed occurring amongst doctors. The research records appear to support those initial observations and anecdotal evidence given by the doctors, thus providing the impetus to start a formal investigation. Primary questions arose from my early observations and conversations with doctors, and included querying why this hostile behaviour was initially happening, and why did it continue to occur. Conjecture includes whether the behaviour is a ‘symptom’ of a systemic problem within the organisation, or within medical education, or the profession as a whole. Also, what role, if any, did power and hierarchy play in the hostile interactions, and did everyone involved, including witnesses, perceive the behaviour as problematic, and if not, why? How did the doctors, both training and trained, define or label this behaviour? There are also some key assumptions embedded in this research. The researcher assumptions include: • Although, arguably, considered by many, to be a privileged cohort, vocationally and organisationally, medical students are essentially in a vulnerable position • Individual medical student experiences and insights are inherently valuable and informative to a multitude of organisational and professional bodies • There are multiplicities of truths or • Power abuse and oppression of any kind are never a positive dynamic • Workplace bullying generally results in greater negative outcomes than positive.

Key areas investigated

The nub of this research stems from some of these preliminary reflections, as it seeks to explore how future doctors, that is medical students, perceive workplace bullying amongst hospital-based doctors. Having limited enculturation into the medical profession and the hospital system, it is considered that medical students are in an position to witness and process behaviours with a greater level of neutrality than full- time residents, registrars or . As there are a growing number of papers quantifying prevalence of workplace bullying amongst doctors, this thesis does not aim to calculate frequency, or even note if bullying has occurred, instead it is considered that

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exploring medical students’ insights of workplace bullying may enhance our understanding of how these hostile interactions are labelled, defined, conceptualised and experienced. Furthermore the current literature tends to frame discussion on perception or experience as a methodological debate, centred on how to gain the most accurate measurement for exposure to bullying behaviours. Generally individual perception, conceptualisation, or experience is discussed in the measurement context of whether self-labelling or behavioural experience should be used to measure prevalence of workplace bullying (Neilsen, Notelaers & Einarsen, 2011). Moreover, within current research, there is often a dialogue around how subjectivity of experience is at the definitional core of workplace bullying, that a bullying event is defined by the individual’s own emotional or cognitive appraisal. The individual may or may not perceive the behaviour as a negative act; however, any discussion of the subjectivity of experience is often confined to the influence of individual on the appraisal. An example of this might be the literature linking individual negative affectivity to the likelihood of ascribing negative meaning to an interaction at work, thereby labelling an experience as bullying when it would otherwise fail to fulfil an operationalised definition of workplace bullying (Hoel, Sheehan, Cooper & Einarsen, 2011). Another instance would be studies that explore the relationship between individual traits such as optimism, resilience, and , and their moderating or exacerbating influence on workplace bullying (Glasø, Matthiesen, Nielsen & Einarsen, 2007; Hutchinson & Hurley, 2013) However, presently, few relatable studies look beyond the influence of when exploring individual perception of bullying experiences. Furthermore professional and organisational context has traditionally been used mainly as a platform to explore and explain antecedents for workplace bullying, or as a reason for perpetuation of workplace bullying, not as a framework for helping us understand individual experience (Baillien et al., 2009; Tuckey, Dollard, Hosking & Winefield, 2009). Raynor and Lewis’ suggestion that a demonstrated variability of tolerance for workplace-bullying behaviours in different organisational contexts is currently under- researched, indicates not only a need for further investigation, but also that there is a potential link between perception of experience and the organisational and professional context (Raynor & Lewis, 2011). The environment that influences workplace bullying to initially occur is multi-causal in nature (Einarsen, Hoel, Zapf & Cooper, 2011). It is therefore conceivable that each component of that context could influence how a

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medical student understands and defines those workplace bullying behaviours and experiences. Consequently the broad areas being investigated in this research are: • Medical student conceptualisations and perception of bullying behaviours • Medical student experiences of workplace bullying by other doctors, both trained and training doctors • The influence of organisation on those perceptions and experiences • The influence of profession on those perceptions and experiences.

The research deliberately focuses on medical student insights, as they are in an ideal position to capture bullying behaviours, both in an observational and experiential capacity, due in part to their low professional and organisational status. Also, as previously noted, the medical students are just starting out in a hospital setting, and they are in a unique position to view bullying behaviours, through a lens which is only newly enculturated to the medical profession, and yet to be thoroughly introduced to the culture of the hospital. While the focus is on the medical students’ perceptions and experiences of bullying amongst hospital-based doctors, given medical students straddle both educational and clinical environments, it is anticipated that participants might share their lived experience insights on bullying behaviours that occur amongst the medical student cohort, or among university Medical Faculty doctors. Although the research will remain centred on medical student insights on bullying between qualified doctors within the hospital context, any data which medical students share regarding bullying behaviours will undoubtedly provide valuable contextualising on behavioural norms or standards. It is worth noting that in the context of this study, the terms conceptualisation and perception are used as two relatively distinct terms. The term ‘conceptualise’ is used as a way to describe a process, the formation of ideas, notions or principles in one’s mind. The idea or notion, that has formed in one’s mind about a certain idea or event, or behaviour, can be assembled from a multiplicity of different places, and experiences, over any time period. The term perception, on the other hand, although describing a similar process to conceptualisation is a relatively immediate awareness of something (in this case bullying, or abrasive behaviours) that is gained through your senses, so, perhaps something you have seen or heard. For example, medical students’ perception of what defines bullying, may be based on something they have seen or

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heard, which leads to their individual interpretation and understanding of abrasive behaviours. Furthermore, mirroring the definitional language used in both relatable studies, and by the research participants, this thesis will at times, use the terms hostile, abrasive, abusive, mistreatment and bullying behaviours interchangeably.

Research questions

The research questions this study is considering are: 1. How do some medical students perceive bullying amongst hospital-based doctors? 2. What are some medical students’ experiences of bullying amongst hospital- based doctors? 3. How might power and oppression dynamics contribute to our understanding of medical students’ perceptions and experiences of bullying amongst hospital- based doctors?

Research overview

While Chapter Five gives detail of the research design and process, this section provides a brief overview of the investigation, and how the above questions and aim are addressed. The participants of this study are medical students, in their final years of education. The students attend one of the four medical schools in the State of Victoria, Australia. There are sixteen medical students in total who have participated in semi- structured interviews, sharing their on bullying amongst hospital-based doctors. Underpinned and framed by a constructivist , this study is qualitative in nature, and employs data collection methods, which aim to capture the full depth and complexity of participant understandings. Thematic analysis is used to further elucidate the experiences and impressions that they share.

1.2. Medical students

A focus of this thesis is medical student perception and experience, and as such, a general outline of the medical student cohort in Australia is unpacked in this section.

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In terms of age of medical students, the average age for students to commence at an Australian is 22, with graduation occurring for 45.1% of students between 25-29 (Medical Deans Australia & New Zealand, 2010 & 2015). In 2015 51.4% of the total number of medical students enrolled in Australian medical schools were female (www.medicaldeans.org.au/statistics/annualtables/accessed 13/02/16). Where medical students studying at Australia universities, are born is outlined in a 2014 survey reporting that over 62% of all Australian medical students are born in Australia, with other countries such as Malaysia, Singapore, China, , Hong Kong, and respectively representing anywhere between 1.2 to 5.3 of the total student cohort (Medical Deans Australia & New Zealand, 2015). A potential implication of a participant’s country of birth is the associated increase of to study a Bachelor of Medicine and Bachelor of Surgery as an International student. In an on-line publication aimed at those considering medicine as a , the Australian Medical Association suggest that for an international full fee paying student, the cost per year is around 65,000AUD (https ://ama. com.au/careers/becoming-a-doctor). The same publication continues to outline in bold type, “full fee paying students are not guaranteed an following graduation from medical school, and may be forced to continue training overseas. You should carefully consider whether you accept this risk when enrolling in a full-fee place” (https ://ama. com.au/careers/becoming-a-doctor, p. 4), in 2013 three-quarters of those students studying medicine in Australia as full fee paying were international students. In relation to the Australian medical student cohort and their identity as Indigenous Australian people, a 2015 data report indicates that in 2014 only 35 Indigenous doctors graduated from Australian medical programs, whilst in 2015, 65 Australian Indigenous students (or 2% of all commencing students) enrolled in year one of medicine (Medical Deans Australia and New Zealand, 2015). A number of peak professional and educative bodies such as AMA (Australian Medical Association), RACS (Royal Australasian College of Surgeons), RACGP (Royal Australian College of General Practitioners), AIDA (Australian Indigenous Doctors’ Association), MDANZ (Medical Deans Australia and New Zealand), and CPMEC (Confederation of Postgraduate Medical Education Councils) are attempting, often in collaborative measures, to increase the number of Indigenous Australians entering Australian medical schools, however the numbers remain significantly low. These numbers are not dissimilar to the 2014-2015 percentage of accepted U.S medical school applicants who

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identify as American Indian or Alaskan Native, which sits at 0.3%, or 0.1% for Native Hawaiian or even lower for Pacific Islander medical students (http://www. aamcdiversity factsandfigures2016.org/report-section/section-3 /#figure-17, accessed 20.08.17).

Medical hierarchy in Victoria

Around the world, and even amongst the Australian States, there is considerable variation as to the labels used to describe each position within medicine. Levels are determined by a measurement of time (i.e. interns must have 47 weeks placement in a hospital to be eligible to move to the rank of resident) and clinical experience (interns must have a combination of experience including 8 weeks of emergency medical care, 10 weeks of surgery, and so on), with the two bottom ranks (after medical student) considered prevocational training (AMA, 2017). Once students have reached a certain level of experience, residents become eligible to apply to an approved medical specialty-training program, and the combination of clinical specialist experience and college examinations make the individual eligible for the level of fellowship, which qualifies them for independent practice. Below is a list of professional rank within the State of Victoria from medical student through to (AMA, 2017): 1. Medical student 2. Intern 3. Resident (Resident Medical Officer) 4. Registrar 5. Fellow 6. Consultant.

In this thesis the term participants and medical students are sometimes used interchangeably. Occasionally medical students, interns, and residents might be referred to collectively as ‘doctors in training’, versus ‘qualified doctors’, those considered in vocational training (registrars), and those who can practice independently (fellowship and above). While Chapter One has provided an outline of the research itself, and the background that led to the study, Chapter Two will explore what workplace bullying ‘looks like’, including the definition of workplace bullying, its prevalence in healthcare, specifically amongst hospital-based doctors, as well as the incidence amongst other

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relatable . Moreover, this chapter will examine the documented consequences or impacts of workplace bullying, on both the individual, and organisation. It will also flag the possibility of impact on the medical profession as a collective. Chapter Two will also raise the concept that bullying may service a purpose, or have a positive impact.

1.3. Outline of the thesis

Part one

Research background (Chapters 1–5)

Chapters One and Two provide relevant background and a broader context in which to embed the research questions relating to workplace bullying amongst hospital-based doctors. Chapter One outlines the circumstances and context in which the study is conducted. The specifics of the research itself are explored and details such as aim, questions, impetus for research, and key areas investigated, are all clarified. Background information covered in Chapter Two includes exploring relevant research and literature, illuminating definitions of workplace bullying, and current labelling debates surrounding the phenomenon. Prevalence of workplace bullying in healthcare, as well as specifically amongst doctors, is investigated, as is bullying in other comparable professional contexts. Chapter Three examines the broader macro, meso and micro context of bullying behaviours amongst hospital-based physicians, and the associated theories surrounding the multi-causality of workplace bullying. It also explores research design and methodology in relatable studies. The legal context of workplace bullying within Australia, and more specifically the State of Victoria are also discussed in Chapter Three. Chapter Four unpacks the role of power and hierarchy in the fostering and facilitation of workplace bullying, as well as any impact on target or bystanders’ experiences and perceptions of those bullying behaviours. Within this chapter, some broader theories or models of power and oppression (and their potential application to bullying in hospitals), as well as medical student perception and experience of workplace bullying amongst hospital-based doctors, are also discussed. Chapter Five discusses the research design. The chapter initially details the methodology used, explaining why qualitative design was appropriate for the research

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focus, the use of interviews and the ethical considerations particular to the research’s methodology. The chapter then considers the research methods, procedures, and process, including target group, research instrument, data analysis, reporting of research and research rigour.

Part two

Research results (Chapters 6–8)

The results chapters detail themes that have arisen from analysis of the semi-structured interviews of medical students. Chapter Six consists of the participants’ demographic profiles, their perceptions of self, and conceptualisations of hierarchy. Chapter Seven unpacks the participants’ perceptions of bullying behaviours, specifically the intergeneration nature of bullying, causation of bullying, prevalence and impacts of workplace bullying, as well as definitional conceptualisations. Chapter Eight details the behaviours that participants either experienced themselves or witnessed. This chapter also includes participant understandings around the connection between environmental context, and the phenomenon of workplace bullying. Participant themes include the professional, organisational (i.e. hospital), professional, institutions (education and professional bodies), and the wider community.

Discussion and conclusions (Chapter 9)

Chapter Nine is a synthesis of existing studies, and the research findings. The intention of this chapter is a response to both the stated aim of the research and the core research questions, in a discussion format that which will lead to knowledge, research and medical education implications. Finally, the limitations and strengths of this research will also be explored, with subsequent conclusions being drawn.

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Chapter 2. What is workplace bullying?

An outline of how workplace bullying is presently defined is necessary in order to start unpacking this research topic. Current literature picks up on a certain amount of discord regarding what defines the act of workplace bullying (Einarsen, Hoel, Zapf & Cooper, 2011). The crux of the definitional difficulties may in the tension between the subjective definition offered by the victim or target of workplace bullying, and the objective, or ‘operationalised’ definition of workplace bullying found in legislation, regulations, and workplace resource departmental policy. As Saunders, Huynh, and Goodman-Delahunty report, any new area of research initially grapples with attempts at establishing an agreed-upon definition of the phenomenon (Saunders et al., 2007). Many research projects exploring workplace bullying, both internationally and within the Australian context, point to an inconsistency of definition, and differences of terms used, with bullying often being referred to as , harassment, mistreatment, or ‘hostile relations at work’. It is suggested that some of these labelling, and definitional differences are initially explained by cultural and language differences (Einarsen et al., 2011). While significant ground has since been made to reach a uniform definition of workplace bullying, the tension between subjective definition and objective criteria still exists. Subjective definitions are based on an individual person’s appraisal of the experience, and are influenced by a variety of organisational, professional, social, cultural, cognitive and psychological spheres (Glasø, Matthiesen, Nielsen & Einarsen, 2007; Saunders et al., 2007; Tuckey, Dollard, Hosking & Winefield, 2009; Einarsen et al., 2011). This research, focuses both on the multiplicity of possible influences found within the organisational and professional context, and on the individual medical students’ conceptualisation, perceptions and experiences of workplace bullying (explored in Chapters Two through to Four).

2.1. The tension of subjectivity and objectivity

There is a tension that sits at the crux of the definition of workplace bullying; this section aims to explore the root cause of this conflict. There are a number of criteria suggested for a generalised, objective definition of workplace bullying, which are discussed later in section 2.2. These criteria are commonly used in the objective conceptualisation of workplace bullying, and the subsequent application or

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operationalisation of legislation, workplace or professional codes and policy or organisational reviews. In relation to an incident or series of workplace bullying events, objectivity has been defined as a situation where, “actual external evidence of bullying is found” (Neilson, Notelaers & Einarsen, 2011, p. 163). One of the early researchers into workplace bullying, Quine suggests that the fundamental criteria for a definition of bullying is a target reported negative effect (Quine, 1999). In fact much of the research and literature measuring the cause and effects of workplace bullying, suggests that it is a phenomenon initially defined by the victim’s perception of events (Quine, 1999, 2002; Salin, 2003; Saunders et al., 2007). So what happens when an individual identifies that they have felt bullied, but there were no witnesses able to validate their perception? This raises the question as to whether this incident can still be called bullying. Conversely, the question can also be asked if someone doesn’t identify as having experienced bullying, yet bystanders define it as such, could it be said that bullying has occurred? It is not uncommon for bullying to be subtle enough to fall under the radar of others (Neilson et al., 2011), although some researchers argue that because of the highly subjective conceptualisation of the bullying process, the significance of certain behaviours may only ever be known by the target and perpetrator, even in the presence of witnesses (Hoel, Sheehan, Cooper & Einarsen, 2011). Hoel et al. contend that workplace bullying, as a psychological phenomenon, can be viewed as a subjective experience but in an investigative process, workplace bullying should be defined by legal, scientific, or investigative definitions (Hoel et al., 2011). In order for the experience to be ratified, it has to be confirmed by witnesses, a third party or measured by using other “objective evidence” (Hoel et al., 2011) The discord in the subjective and objective definitions and experience, is highlighted should that personal perception of bullying need to be viewed using an objective third party lens, for example for a workplace investigation. In terms of definition and labelling of workplace bullying, the questions that remain largely unanswered by research and literature include: Are the target’s subjective perceptions of a workplace bullying experience, reflected in the definitions and application of objective standards? Is there a disparity between what behaviour someone might experience in the workplace, and how they might define it, and then how it might be defined objectively? Is it possible that a new, broader definition can be established that validates the uniqueness of the individual experience? Like Saunders et al. (2007), Quine points out that to date, much of the that defines workplace bullying has traditionally been influenced

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by case law (Quine, 1999). There are however, several problems with using the law to help define an issue like workplace bullying. Lippel points out that objective legal definitions are effective for measuring prevalence of a phenomenon, or in a legal context, regulating behaviour, but for those laymen and practitioners trying to understand how to prevent workplace bullying from occurring, they need to look towards other sectors for influence (Lippel, 2010). As Saunders et al. suggest, legal definitions of workplace bullying tend to parallel scientific definitions, which are used for measuring negative behaviours, longevity and frequency of behaviour, as well as the harm that was inflicted on the target (Saunders et al., 2007). While these are all vital elements in helping us understand more about the bullying process, these definitions do not help us understand how and why a target, perpetrator or bystander might conceptualise their experience in a particular way, or what significance a person places on certain behaviours, nor what criteria the individual uses to determine if bullying has taken place. Objective definitions used in codes, policy, and legislation are at risk of undermining what many researchers have acknowledged; that the “definitional core of bullying at work rests on the subjective perception made by the victim” (Niedl cited in Einarsen et al., 2011, p. 16). There is currently a gap in research that qualitatively explores the victim’s personal understanding of experience, as well as juxtaposing that personal conceptualisation with the objective operationalised definitions of workplace bullying. It is a focus of this research to explore tensions or dissonance between individual medical students conceptualisations and objective definitions of work place bullying. Also currently overlooked in research is an explication of how environmental factors such as organisation or profession might influence a worker’s individual perception of bullying in their workplace. Perhaps the paper that comes closest to investigating some key elements of the definitional questions, is in the Australian study by Saunders who wrote on ‘Defining workplace bullying behaviour professional lay definitions of workplace bullying’ in the International Journal of (Saunders et al., 2007). This study examines the similarities and differences in definitions between the layperson’s experience, and the objective operational definitions of workplace bullying (Saunders et al., 2007). The study asks a range of 1095 , from diverse backgrounds, via an online survey “what is your definition of workplace bullying”? (Saunders et al., 2007, p. 347). The study hypothesises that the lay definitions would have some overlap with the objective,

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legal or scientific definitions, with the results confirming their hypothesis. The overlap however, was limited. The highest rate of congruence between operational and lay definition was in the “perpetration of a negative behaviour”, with 98.3% of respondents citing that a negative act was an essential element of workplace bullying (Saunders et al., 2007, p. 345). Only 14.7% of the participants felt that persistence or frequency was necessary for a label of bullying to be used. One person wrote that bullying occurs “when an employee is made to feel uncomfortable, unsafe or unhappy in the workplace; sometimes this only happens once” (Saunders et al., 2007, p. 351). These results are in stark contrast to the definitions used in many research studies. Interestingly, none of the respondents included that the victim must feel bullied, or that “the target must label the experience as bullying” (Saunders et al., 2007, p. 345). Moreover, 25.5% of participants also noted, that by definition, bullying in the workplace was a violation of expected workplace norms, and 21.4% felt that intent of the bully was important (Saunders et al., 2007). However, what this study does not investigate is the individually identified influences, that is, both the environmental and the psychological or emotional spheres that have led the person to conceptualise certain behaviours as bullying, or not. Nor does it explore the significance that individuals, be they target, bully or bystander, might attach to certain abrasive or hostile behaviours. It stops short therefore, at being able to elucidate why a worker who was being bullied using an objective definition, fails to self-report as being bullied. Comparisons between the definitional perceptions of the target, bullies and observers might also be an important study when trying to understand the variability in an individuals understanding of bullying.

2.2. Core criteria for workplace bullying

The following 5-core criteria are sometimes used in research to work out if an event can objectively be labelled ‘workplace bullying’ (Cheema, Ahmad, Naqvi, Giri & Kallaperumal, 2005; Hauge, Skogstad & Einarsen, 2007; Scott, Blanshard, & , 2008; Askew et al., 2012). These definitional criteria can often be found in workplace bullying studies and investigations, as well as embedded in organisational Codes of Conduct, legally binding Acts of law, organisational and professional policy and regulations.

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Negative impact

One of the core criterions of a definition of workplace bullying is that the interaction has a negative impact or outcome for the target of the behaviour. Negative acts, however, must be observed, reported or confirmed by others for bullying to have been objectively identified and defined as such. Saunders et al. suggests that the target of the bullying must experience “some form of psychological, emotional or physical harm” (Saunders et al., 2007 p. 342). In their Workplace Bullying and Harassment Position Statement, the AMA that the term bullying includes negative behaviours that create “a risk to health and safety” (AMA, 2015a, p. 1). Workplace bullying researchers also defines bullying at work as “harassing, offending, or socially excluding someone or negatively affecting someone’s work” (Einarsen et al., 2011, p. 22). The RACS Expert Advisory Group on discrimination, bullying and reports that bullying is behaviour which one could expect to “victimise, humiliate, undermine or threaten” (RACS, 2015a, p. 19). Interestingly this definition changes slightly when it was later included in the Australian Senate enquiry, to include the terms “offends, degrades, and ” (RACS, 2015, p. 19 cited in the Commonwealth of Australia, 2016). A 2014 study into medical student perceptions of mistreatment report that students who feel mistreated have higher rates of , , loss of , decreased work satisfaction, and an increase in suicidal thoughts (Gan & Snell, 2014). Furthermore, an Australian survey study of workplace bullying in a health sector organisation, refer to a number of long-term negative effects that workplace bullying can have on targets (Rutherford & Rissel, 2004).

Repeated behaviours

The study by Saunders on workplace bullying definitions, initially suggests that repetition or persistence of negative behaviours are an essential element that make up a universally accepted, objective workplace bullying definition (Saunders et al., 2007). WorkSafe Victoria defines workplace bullying as being “characterised by persistent and repeated negative behaviour” (WorkSafe Victoria, 2012, p. 2). Furthermore, the Victorian Act (1958) 21A (2), which relates to penalising behaviours which could be interpreted as bullying, mentions offenders engaging “in a course of conduct”, indicating that there would be more than one action or incident for an offence to have occurred. Amendments made in 2011, to the Victorian Crimes Act were made in direct

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response to the workplace bullying case of Ms Brodie Panlock. The coroner’s comment in the Brodie Panlock Case, reported that the perpetrators were “relentless in their efforts to demean”. In sentencing the perpetrators in the Brodie Panlock case, the Magistrate described the actions of perpetrators as “persistent and vicious behaviour” (Butcher, 2011). Further discussion of the case can be found in Chapter Three. In the second edition of the seminal text Bullying and Harassment in the Workplace, Einarsen et al. also argue that the term bullying does not normally include “single and isolated events”, but instead is characterised by behaviours that are persistent and repeated (Einarsen et al., 2011, p. 11). It has been suggested that in-order for the label bullying to be applied to an incident or hostile event, that the bullying behaviour has to occur repeatedly and regularly (e.g. weekly) and over a period or length of time (Eirnarsen et al., 2011). Furthermore, a key recommendation from an Australian Parliamentary House of Representatives inquiry into workplace bullying was the nationwide adoption of a definition, which includes that “workplace bullying is repeated, unreasonable behaviour…” (Commonwealth of Australia, 2012, ixx) However, as mentioned previously, the Saunders et al. study results also revealed that repetition was not deemed imperative by the majority of lay people in their definition of workplace bullying (Saunders et al., 2007). The question could be asked, can you feel bullied, or legitimately claim, to have been bullied, if the perpetrator has only done it to you once? What if the ‘wrongdoer’ is an individual known to be a bully, and who has separately committed abrasive or hostile behaviours to all the individuals in your cohort? Do singular acts of bullying (or oppression or ) by one person, to multiple individuals, in one particular group not constitute bullying? The Australian Medical Association (AMA) is the professional body that represents, regulates and informs Australian doctors, and in their position statement on Workplace Bullying and Harassment they define bullying as “behaviour that is repeated over time or occurs as part of a pattern of behaviour” (AMA, 2015a, p. 1). However, unlike the majority of professional or organisational codes or policies regulating workplace bullying, the earlier 2009 version of the AMA definition acknowledged that bullying might occur as “a single event” (AMA, 2009, p.1). In 2016 the Australian Medical Students’ Association (AMSA) included this definition in their submission to the Australian Senate inquiry on bullying and harassment in the medical profession (AMSA, 2015). Although often considered imperative for a definition of bullying,

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tensions still remain around the inclusion of repetition in a core characterisation of workplace bullying.

Duration and systematic

Research sometimes indicates that bullying is an escalating process that occurs over a length of time, and in the course of which the person confronted ends up in an inferior hierarchical position and becomes “the target of systematic negative social acts.” (Einarsen et al., 2011, p. 22). An Australian survey of 747 doctors uses the definition of workplace bullying as ‘repeated’ and ‘systemic’ behaviours, and questions participants about any ‘persistent’ abrasive behaviours that they’d experienced over a 12 month period (Askew et al., 2012). Similarly a study from the uses the term “persistently bullied or undermined”, and measures bullying amongst obstetricians and gynaecologists in spans of duration in increments ranging from “over the last 12 months” to “longer than 5 years” (Shabazz, Parry-Smith, Oates, Henderson & Mountfield, 2016). Many national and international studies, exploring workplace bullying in medicine, use the definitional yardstick that bullying is “a pattern of aggressive behaviour that escalates over time” (Bairy, Thirumalaikolundusubramanian, Sivagnanam & Saraswathi, 2007, p. 87).

Power differential

Researchers also sometimes preclude the use of the label ‘bullying’ on events that occur between a ‘victim’ and ‘perpetrator’ who are of equal standing within the workplace (Einarsen et al., 2011). A recurring theme within much of the literature is the significant part that power differentials play in the generation and perpetuation of bullying. The difference in power can be embedded in actual structural hierarchy or simply the perception of power difference between people. As the respondent in one Canadian study on medical students’ perception of mistreatment suggests, “ If you’re in a situation that you feel is a bad situation and you don’t have the power to change it, that could be very destructive.” (Gan & Snell, 2014, p. 612). Einarsen et al. go so far as to even suggest that without a difference of power between victim and perpetrator, then the label of bullying cannot be used (Einarsen et al., 2011, p. 22)

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Targets of bullying label themselves as having been bullied

In her study on labels and definitions of workplace bullying Saunders et al., suggests that another core component of a definition of workplace bullying is the perception that the target feels bullied (Saunders et al., 2007, p. 342). Additionally, Scott et al., wrote an article on their questionnaire survey examining workplace bullying of junior doctors, reporting that bullying is defined by the perception of the target, and that it is the target’s identification of having been impacted negatively by abrasive actions that ultimately labels a behaviour as bullying, or not (Scott et al., 2008). Salin, in her 2003 article reviewing different environmental work structures and processes which enables or fosters workplace bullying, agrees that the negative perception of the interaction is defined by the victim’s “own of the situation” (Salin, 2003, p. 1213). Again, this definitional criterion raises the question of what we might call hostile behaviours that tick all the other criteria boxes, yet the target themselves does not identify as being bullied. This criterion brings us back to the questions of whether behaviour can still be labelled as ‘bullying’, if only a bystander, and not the target, labels it as such.

2.3. Why is it important to define the term ‘bullying’?

Arguably, having a broadly accepted, independent definition of workplace bullying, allows for unambiguous rules to be developed in terms of what behaviour is acceptable and what is unacceptable. A majority of doctors interviewed in an American study wanted “black-and-white rules and disciplinary procedures to govern ” (Weber, 2004, p. 10). It could be argued that unless there is a clear, universal definition of workplace bullying, when it comes to sanctioning or monitoring workplace conduct, the significant challenge for individuals and organisations to conduct fair, effective investigations into workplace misconduct will remain. However, repeatedly in research, the issue of ‘subjectivity’ of experience comes up in relation to perception of behaviours as either bullying, or not. This tension is persistent in its presence, and should be recognised not as a hindrance to the possibility of a universally accepted definition, but rather, as the potential key to developing a more inclusive definition of bullying. The continued existence of this tension may indicate the need for a definition that validates a breadth of experiences. It is valuable to flag that any definition of workplace bullying will perhaps be influenced by the immediate

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environment and the broader social culture in which the bullying occurs, and likewise any definition of bullying will have reverse potential to influence events within its immediate and wider context. Some workplace bullying experts believe that ongoing debate regarding definition can distract from more pressing matters, “I think that sometimes saying that there is no definition or that it is still controversial is almost a barrier to doing something about this. I do not think we should be seduced by that at all” (Caponecchia, cited in Commonwealth of Australia, 2012, p. 14).

2.4. Prevalence of workplace bullying

This section unpacks what is known about the prevalence levels of workplace bullying. While acknowledging the complexities inherent in defining workplace bullying, it has been suggested that bullying can actually occur anywhere there are two people (Liefooghe & Davey, 2001), furthermore it has also been argued that an organisation itself can be responsible for bullying an individual worker (Liefooghe & Davey, 2001). An earlier Australian parliamentary inquiry into workplace bullying by the House of Representatives, Standing Committee on Education and , remarks on the inherent difficulty in measuring prevalence of bullying, describing it as “a hidden problem” (Commonwealth of Australia, 2012, p. 8). Using the definition outlined in this chapter, it is more than likely that bullying will also be found in most systems, industries and sectors outside health. Unlike bullying amongst doctors, there is a considerable amount of literature, which has been written, about bullying amongst nurses. Although this thesis contains some discussion of bullying in , particularly in reference to the power dynamics that characterise bullying amongst nurses, it was a deliberate choice of the researcher to not include detailed comparisons of the nursing profession, or any other profession that predominately operates within the healthcare setting. The education and legal sectors are two broad professional areas that are distinct from, yet approximate with the healthcare sector. All these sectors house multiple organisations, systems and professions who are all working in a relatively integrated fashion for the beneficial outcome of individuals or . Similarities can be found between occupations within the legal and education sector, which include congruence of community status, levels of organisational and professional hierarchy, as well as mentor training models, and funding sources. It is for those reasons that brief

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summaries of bullying amongst these professions have been included in the section on prevalence. There are however, some limitations to prevalence studies, worth noting. As with the previously discussed tension found between subjective definitions and experiences, and objective (operationalised) definitions of bullying, it can be recognised that our understanding of workplace bullying prevalence relies on the victim reporting the event, either by self-labelling or identifying a behavioural experience (Einarsen et al., 2011). With self-labelling surveys, participants may not recognise, when using or providing an objective definition that they have experienced bullying behaviour, and therefore they might respond that they have not being bullied. Even if an operationalised definition is provided by the researchers, and the participant responds ‘yes’, the prevalence studies fail to tell us if that person actually ‘felt bullied’, or would even have normally defined the experience as bullying. There are limits evident in what information can be gleaned from some of the quantitative, questionnaire, or survey based prevalence studies.

Bullying in healthcare

Although the discussion in this section focuses on prevalence of bullying in a healthcare setting, and often with an emphasis on physicians, it is also inclusive of literature that explores mistreatment, abuse, humiliation or bullying behaviours of medical students. While much research focuses on mistreatment or abuse of medical students in a clinical setting, medical students uniquely straddle both the healthcare and educational sectors indicating that from a perspective of hierarchy and power dynamics, they are arguably in a position of compounded both within their educational institution and their healthcare organisation. Many national and international researchers and physicians alike, argue that hostile, mistreating and bullying behaviours amongst doctors are widespread, and continue to have serious negative consequences for both doctors, and potentially their patients (Quine, 1999; Paice, Aitken, Houghton & Firth-Cozens, 2004; Cheema et al., 2005; Scott et al., 2008 Imran, Jawaid, Haider & Masood 2010; Hills, Joyce & Humphreys, 2011; Askew et al., 2012; Resident Doctors of Canada, 2013; Royal Australasian College of Surgeons, 2015a,b,c; Shabazz et al., 2016). Bullying behaviours amongst doctors is not a new phenomenon, and they have been periodically documented

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over at least three decades. Furthermore, hostile interactions between qualified doctors, and medical students have been intermittently documented for at least five decades, with the ethnographic study, Boys in White first published in 1961 and detailing abusive interactions between senior doctors, educationalists and medical students. The label of workplace bullying, was noted at it’s earliest, by Scandinavian researcher, Leymann who coined the concept and label of bullying amongst adults, in an organisation, during the late 1980s (Leymann, 1986, 1990). However, in America, Silver wrote of systemic abuse that medical students were at the hands of older, more experienced physicians even earlier, in 1982 (Silver, 1982). While Silver didn’t use the term ‘bullying’, much of the behaviours he outlines correlate with researchers’ definition of bullying. A more recent pilot study conducted in Victoria, Australia, indicates that 74% of medical students on clinical rotation have experienced humiliation and mistreatment, with 83.6% having witnessed it (Scott, Caldwell, Barnes, & Barrett, 2015). Academic humiliation as a form of bullying is seen not just in local studies but also internationally. The cross-sectional survey of 654 junior Pakistani doctors reveal that belittling and undermining work, unjustified and monitoring of work, and persistent attempts to humiliate in front of colleagues, were the top three categories of bullying behaviours reported by the respondents (Imran et al., 2010). The practice of academic humiliation is not new, in fact, large-scale questionnaires completed by American medical students, has captured academic humiliation over the decades. A 1998 article published in Academic Medicine, reported that of the 13,168 students who took part in the survey that year, 38.3% reported being “publicly belittled or humiliated at least once” during their time at medical school (Kassebaum & Cutler, 1998, p. 1151). Interestingly, in academic and educational research the label of medical student ‘abuse’ and ‘mistreatment’ have persisted to this day. In the United Kingdom, Quine’s earliest study exploring workplace bullying amongst doctors and other health professionals, took place in the late 1990s, using data from a 1996 questionnaire survey (Quine, 1999). Elaborating on the workplace-bullying studies where doctors are the central participants, the data that follows is drawn from a combination of international and Australian investigations and studies (Quine, 2002 Rutherford & Rissel, 2004; Cheema et al., 2005; Bairy et al., 2007; Scott et al., 2008; Hills et al., 2011; Askew et al, 2012; Timm, 2014; Ivory, 2015; Scott et al., 2015; RACS, 2015a; RACS, 2015b). It is important to note that the definition is not always consistent across studies, nor is the

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way it is measured. An illustration of definitional differences in research is found in the question asked to ascertain exposure to bullying in Askew et al.’s study, “In the last 12 months, have you been subjected to persistent behaviour by others which has eroded your professional confidence or self esteem?” (Askew et al, 2012, p. 199), versus the definition of bullying provided to participants in a study by Timm, “bullying or harassment refers to something happening which is unwelcome, unwarranted and causes detrimental effect” (Timm, 2014, p. 2). Another example is, Quine’s 2002 British study, which measures the bullying event by single behaviour, but a New Zealand study uses multiple episodes or incidences (Scott et al., 2008). Furthermore, many of these studies have been conducted in countries other than Australia, so it is important to be cognisant of the potential cultural influences on subjective perceptions, experience, definition and research outcome. In 2001 the British Medical Association sent out questionnaires, to 1000 doctors. The outcome of this questionnaire is that 37% of junior doctors report being bullied in the previous year, and 84% have experienced at least one type of bullying behaviour (Quine, 2002). Further to this, the New Zealand study by Scott et al. mentioned above, suggests that workplace bullying in hospitals is a “significant issue with junior doctors” (Scott et al., 2008, p. 1281) with 50% of responders experiencing at least one episode of bullying. A study conducted in Tamil Nadu reports that nearly 50% of the 174 doctors who participated have been bullied, and suggests, “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” (Bairy et al., 2007, p. 89). Although a relatively new phenomenon, one study conducted in the United Kingdom, indicates that 46.2% of the 158 trainee doctors surveyed had also experienced a minimum of one act of during their training (Farley Coyne, Sprigg, Axtell & Subramanian, 2015). A 2011 Australian study, entitled ‘Prevalence and prevention of workplace in Australian clinical medical practice’ explores the prevalence of in healthcare settings (Hills et al., 2011). Using data from 321 doctors who completed a survey on frequency of acts of aggression directed at them, from either patients, external persons, patient careers or relatives, more than 70% of doctors report experiencing verbal or written aggression one or more times in the previous 12 months. Of that 70%, 27.9% was aggression from co-workers. This same study also found that

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those doctors working in hospitals were at two to four times higher risk of workplace bullying than doctors working outside the institutions (Hills et al., 2011). Additionally a survey of Australian doctors, reports that 25% of the 747 participants have experienced behaviours consistent with bullying and harassment in the previous 12 months (Askew et al., 2012). An Australian survey conducted in 2004 at a ‘NSW health service’, suggests that most respondents who do “face-to-face clinical work with clients” are one and a half times more likely to be bullied than those who were in administrative support roles (Rutherford & Rissel, 2004, p. 69). Furthermore, 49% of staff report that their peers are the largest source of bullying (Rutherford & Rissel, 2004). The Australian Medical Association have used this study in their AMA Workplace bullying and harassment position statement (2015) suggesting in their introduction that 50% of doctors have experienced at least one episode of bullying behaviour during their previous three or six month clinical rotation (AMA, 2015a). As previously mentioned, recently in Australia, the documented interest in bullying amongst doctors, particularly bullying of young doctors, has risen from within the medical profession itself. Related topics such as the sexual harassment of female surgeons, and and rates of all doctors, have also seen an enormous spike in public awareness, driven in part by the focus from all areas of the media on the issue. A public outcry ensued, at the sexual harassment and bullying reported by senior female surgeons, as well as junior doctors. As a result of the increased community and media attention, a number of new prevalence studies are currently being carried out, including investigations by the Australian Medical Students Association (AMSA), and university researchers. One, yet to be published study suggests that investigators found “74% of Australian students experienced mistreatment during clinical placements and even more witnessed it” (Ivory & Scott, 2015) The Royal Australasian College of Surgeons’ Expert Advisory Group on discrimination, bullying and sexual harassment found that of the 3500 doctors who shared their experiences of discrimination, bullying, and sexual harassment, 54% of trainees reported experiences of bullying (RACS, 2015b). This study also found that 71% of Australian hospitals reported bullying, discrimination or sexual harassment within the last five years, with bullying is the most frequently reported issue (RACS, 2015b). It is, however, unclear which healthcare professions where involved in reporting the behaviours.

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Up until recently, much of the literature on workplace bullying in the healthcare sector tended to consistently focus on nurses, whose rates of bullying have also been acknowledged as high (Dellasega, 2009; Cleary, Hunt & Horsfall, 2010; Farrell & Shafiei, 2012; Douglas, 2014). Reports of nurses’ exposure to bullying behaviours in the workplace ranges from 63% upwards to 95%, with one Australian study of over 200 nurses reporting that 34.3% have been exposed at varying rates of regularity, to the negative consequences of aggressive bullying behaviours (Demir & Rodwell, 2012). One reason for the difference in research between doctors and nurses might be found in the divergence of responses to the behaviour, with some research suggesting that nurses and nursing students are more likely to challenge and report the abrasive behaviours than the medical students (Timm, 2014). It is interesting to note that much of the documented bullying that appears to occur amongst nurses happens horizontally, although recent studies have also noted an increasing tendency for nurses to bully vertically, from senior nurse to student nurse (Thomas & Burk, 2009; Courtney-Pratt & Pich, 2017). Research also suggests that it is nurses within the same or similar work experience band who are tending to bully each other (Dellasega, 2009). Although bullying amongst doctors can occur horizontally or upwardly, with a 2016 study of bullying amongst obstetricians and gynaecologists, reporting that 12% of senior doctors are bullied by junior physicians (Shabazz et al., 2016), it appears from research that much bullying amongst doctors transpires vertically, from top down (Quine, 2002; Scott et al., 2008; Imran et al., 2010).

Bullying in the education sector

There are a number of studies, within education institutions, primary, secondary and tertiary that focus on bullying between staff, between staff and students, and between students. Given the core of this research is exploring medical students’ perceptions and experiences of bullying behaviours amongst highly educated and trained professionals, working within a strongly hierarchical, and at times stressful environment, it seemed a salient choice to explore literature dealing with intra- bullying, and bullying between staff members and students. The majority of papers on bullying within the education sector highlight both the high prevalence of bullying, and the plethora of negative outcomes. One Australian study into self-reported and bullying in Australian Universities, suggests that amongst academics,

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24% of staff in a Go8 (Group of 8, which is a coalition of research intensive Australian universities) university, 32% of staff based at a metropolitan university, and 37% of regional academic staff reported harassment and bullying (Skinner et al., 2015). Internationally, one United Kingdom study notes a difference in bullying rates between , with 28.4% of female academics likely to be bullied, versus 19.8 % of male staff (Simpson & Cohen, 2004). A study of academic staff within a Turkish nursing faculty report that 91% of the staff they interviewed have encountered workplace bullying (Yildirim, Yildirim & Timucin, 2007), with 17% being directly affected by it. Thomas Heckler cites ’s formative studies on workplace bullying, reporting that bullying takes place “in schools, universities, and libraries at twice the rate of workplace in general” (Heckler, 2007, p. 442). However, neither Leymann nor Heckler are able to give definitive reasons as to why this might be the case, although research has since shown that educational institutions often have a number of environmental antecedents that increase the risks of workplace bullying occurring (Salin, 2003). This same educational environment has also been shown to produce a high level of bullying from medicine faculty staff to medical students, with one study of 665 participants reporting that half of the students have experienced some form of ‘mistreatment’ by staff during their university studies, most commonly humiliation and contempt (40%), disparaging remarks (34%) or yelling or shouting (23%) (Rautio, Sunnari, Nuutinen & Litala, 2005). Although the study by Rautio does not frame the enquiry in terms of workplace bullying, they note that ‘extensive mistreatment’, which they label as multiple types of mistreatment affects close to 11% of the students interviewed (Rautio et al., 2005). Moreover, the students from the Faculty of Medicine report “every form of mistreatment more commonly than those in the Faculties of Humanities, Education, Science and Technology” (Rautio et al., 2005, p. 36), pointing perhaps to the embryonic stages of a distinct professional culture, which will not only foster or tolerate workplace mistreatment, but may also be influential in developing trainee doctors’ understandings of what bullying means. Chapter Three explores further the influence of organisational and professional context on workplace bullying, as well as exploring language choice to define the phenomenon.

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Bullying within the legal system

The legal system, including law firms, court houses, barrister chambers and the police force also share a number of similarities to organisations and medical institutions within the healthcare system, and as such have also been included in this review. The focus of many of these studies includes prevalence, causation and outcomes. An Australian study of 716 police officers purports levels of workplace bullying sitting at around 12.6%, which are reported as on a par with other sectors but interestingly the study by Tuckey et al., suggests that along with ‘psychosocial work environment’ factors contributing to the cause, bullying “may be a way of maintaining the pecking order and enforcing discipline within the hierarchy” (Tuckey et al., 2009, p. 226). A future study which compares the amount of police officers who self-report being bullied versus the number of participants who meet the provided objective criteria for bullying, may highlight a significant difference in numbers, further demonstrating that tensions between subjective conceptualisation and definition is of potential importance to a more complete understanding of the phenomenon (Tuckey et al., 2009). Also a 2015 independent report provides statistics that 40% of females working in the police force have experienced sexual harassment, with 24% of all police having witnessed bullying and 20% having personally experienced workplace bullying (Victorian and Commission, 2015). As well as a number of media articles outlining the presence and prevalence of bullying within the legal system, both nationally and internationally (Oakes, 2012; Alexander, 2013) one American study of workplace bullying amongst federal court employees found that around 71% of the 1,167 respondents had had some experience of “interpersonal mistreatment in their workplace in the previous 5 years” (Cortina & Magley, 2003, p. 255). Also, an online survey conducted by the Australian publication, Lawyers Weekly, found that of the 460 lawyers who answered their question, ‘Is bullying a problem in your firm’, 33% answered yes, and went on to elaborate that firm partners (senior staff), were the biggest perpetrators of bullying junior staff (Lawyers Weekly, 2013). An article in the Journal Legal Ethics, reports that bullying in Australian law firms is at pandemic proportions, due in part to power relations, a workplace culture that is permissive of bullying, and high levels of job related stress (Bagust, 2014). The article further contends that the unhealthy levels of stress found in law firms is even more concentrated in law students, citing a statistic that has psychological stress levels

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of law students higher even than those of graduate psychology, chemistry and medical students (Bagust, 2014).

2.5. Consequences of workplace bullying

While there are a number of studies which establish that workplace bullying as a general concept has a range of adverse effects on the victim, bystanders, bully and the work organisation as a whole, there are few known studies which explore specifically either medical student perception of bullying impact, or the actual experience of that impact. Additionally there are no known studies exploring the impact of bullying on the medical profession as a collective. This section outlines a range of broad potential consequences as identified in the literature.

Negative individual effects of workplace bullying

There are a variety of individual impacts of workplace bullying, which have been captured by research both nationally and internationally. The discussion in this section covers the current negative consequences reported in relevant research literature, and pertaining to individual negative impacts, in particular focusing on physical, emotional and psychological effects. Physically, negative effects on the individual include a suggested increase in bodily illness, from coronary heart disease, immune system dysfunction, and on a cellular level, accelerated telomere shortening; which in turn may lead to early onset of age-related diseases (Epel et al., 2004; Kivimäki et al., 2005). Increased incidence of mental illness and adverse psychological outcomes, such as substance addiction, , depression, post-traumatic stress, and disorders have also been reported (Vartia, 2001; Caponecchia & Wyatt, 2011; Askew et al., 2012; Carter et al., 2013; Shabazz et al., 2016). Research investigating a connection between medical student ‘mistreatment’ or abuse, and posttraumatic stress disorder found that not only had the majority of their respondents been subjected to, or witnessed abuse (from a variety of different sources), but that the average score on the Impact Event Scale-Revised (IES-R) was within the “symptomatic range for posttraumatic stress symptoms” (Heru, Gagne & Strong, 2009, p. 305). Individual negative impacts of workplace bullying can have a ripple effect on those around them, co-workers, friends, and . Brodie Panlock took her own life after being bullied at the café where she worked, and her father said in the Australian

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House of Representatives inquiry into workplace bullying “It impacted on our family. It was not just Brodie…. it has affected our family and it is nearly six years. It affected the whole family. It is not just us but our other children, their grandparents, and so on” (Panlock, cited in Commonwealth of Australia, 2012, p. 13) However, literature also indicates that there appears to be some moderating factors when it comes to impact, or effect of workplace bullying on the individual. A 2012 study on the impact of bullying on Australian administration staff indicate that effects were moderated by whether the employee was full or part-time, with full-time employees reporting higher levels of psychological distress and significantly lower levels of commitment to the organisation than bullied part-time workers (Rodwell ,Demir, Parris, Steane & Noblet, 2012). Studies also indicate that reported levels of psychological distress in bullied healthcare workers are higher for those aged 45 years or older compared with individuals aged 44 years or less (Demir, Rodwell & Flower, 2013). Victims and bystanders of workplace bullying frequently comment on the individual negative effect of persistent or incessantly abusive behaviour, with one study of bullying amongst staff in the UK National Health Service (NHS), recording a direct correlation between the frequency of both experiencing and witnessing bullying, and higher levels of psychological distress (Carter et al., 2013). There are several studies, which report a correlation between bullying amongst hospital-based doctors and a negative impact on the patient. One American survey on disruptive, harassing, or abrasive physician behaviours reports that 71% of participants believe there is strong correlation between the physicians abrasive behaviours and medical errors, with 51% feeling that the behaviour compromises patient safety (Rosenstein, 2011). Earlier research with medical students also indicates that 15% of the 147 students surveyed noted a direct correlation between “student abuse and the subsequent mistreatment of patients” (Margittai cited in Bourgeois et al., 1993). Furthermore, a British study reports that over 50% of the 229 obstetricians and gynaecology consultants and fellows who had reported being bullied, could be delivering compromised individual patient care as a result of the significant impacts of that bullying (Shabazz et al., 2016).

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Organisational effects of workplace bullying

The impact of workplace bullying on organisations can also be considerable. Studies indicate that , presenteeism, reputational harm, staff loss and compensatory claims all contribute to the adverse effects of workplace bullying on an organisation. These organisational impacts are documented as loss of talent, expensive , and staff recruitment difficulties (Kivimäki, Elovainio & Vahtera, 2000; Namie, 2005; Rosenstein, 2011; Askew et al., 2012, Magee et al., 2014). A State Services Authority survey conducted over a 10-year period outlines how workplace bullying can lead to lower rate, increased rates of absenteeism, poor , decreased , an increase in workers compensation claims as well as the of litigation (VPSC, 2016). Additionally, the survey of nearly 3,000 NHS staff, found that those who had witnessed and experienced bullying directly reported higher levels of intention to leave work (Carter et al., 2013). A study on workplace bullying, prepared for organisation beyondblue, reports that stress-related presenteeism Australian an estimated $9.69 billion dollars annually (Magee et al., 2014). A 2016 audit conducted into bullying and harassment in the health sector, flagged a 2010 figure by the Productivity Commission that estimated the total cost to the Australian economy of workplace bullying alone, was somewhere between $6 billion and $36 billion annually (Victorian Auditor-General, 2016). Further to this, an Australian on-line cross-sectional survey of 747 doctors found that doctors who reported that they were bullied, had taken more sick-leave in the last 12 months, and were planning on decreasing the number of worked in the next 12 months (Askew et al., 2012). The same group of bullied doctors also reported that they were more likely to cease direct patient care in the next 5 years (irrespective of age or number of hours currently working), compared to their non-bullied counterparts (Askew et al., 2012).

Impact of workplace bullying on the medical profession

Bullying amongst doctors has the potential to impact the medical profession as a collective; this section explores that concept further. There are currently no known studies that examine the collective professional impact of bullying amongst its members. However, within the broader Australian community context of this research, the medical profession as a group has came under intense public scrutiny as the result of protracted media coverage surrounding bullying and harassment in medicine. Between

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2015 and 2016 Australian published multiple articles and current affairs broadcast programs, with a particular focus on individual perpetrators and victims (examples include Alexander, 2015; Medew, 2015a,b,c; Srivastava, 2015; Doherty, 2016). As mentioned in Chapter One, this extensive media coverage prompted a series of professionally driven investigations, reports and parliamentary inquiries. While there is no current literature exploring the subsequent impact that such focused, relentless scrutiny may have had on the profession as a collective, both from a lay person’s perspective, and from within the medical membership, it is worth acknowledging that bullying behaviours within medicine may well also command an impact on the profession’s as a collective.

2.6. Can bullying serve a purpose, or have a positive impact?

Is it possible that bullying could have a positive impact, or perhaps it serves a purpose? There is some research indicating that the outcomes of workplace bullying are potentially advantageous for certain individuals, and organisations in particular circumstances. Ferris, Zinko, Brouer, Buckley & Harvey (2007) explore the concept of using bullying as a tactic to produce positive outcomes, suggesting that bullying can increase the perpetrators profile within the organisation, ‘he gets the job done’, or from an organisational point of view, the perpetrator can help rid the organisation of staff they feel are ineffective (Ferris et al., 2007). Ferris concludes “politically skilled leaders may use bullying in a manner that can result in positive consequences for them or the organisation. By bullying ‘low maturity' targets, there are potential positive outcomes not only for organisations, but for bullies as well.” (Ferris et al., 2007, p. 203). There is also research that explores possible positive outcomes for the targets of workplace bullying. One study of social workers that identify as having being bullied in the workplace, indicate that a number of the targets, or victims of the abrasive behaviours had reported a gain of positive outcomes from being bullying (van Heugten, 2012). The positive gains noted include an increased sense of personal mastery, resilience, an improved sense of control, social inclusion and support from bystanders (van Heugten, 2012). Moreover, an editorial in Anaesthesia Journal discusses bullying in a medical context and asks the question of its readers, whether there is ‘an acceptable level of bullying’? (Dickson, 2005). The editorial continues to discuss reasons for bullying,

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other research results, and suggests that unintentional bullying might “at times, be understandable” (Dickson, 2005, p. 1160). The comments made in the above editorial, mirror results of the Australian study by Scott et al., which reports that between 30% and 50% of medical students feel that the humiliation or they witnessed or experienced during clinical placement was useful to learning (Scott et al., 2015). In the study by Gan and Snell, some participants report a perception that abrasive interactions could actually facilitate an increase in capability and resilience (Gan and Snell, 2014). There is clearly an argument being forwarded by some trainee and qualified doctors that incidents of bullying can have ‘benefits’.

2.7. Chapter summary

Chapter Two explored some of the tensions and current debates in defining workplace bullying, as well as outlining issues with, and rates of, prevalence. The chapter also examined some of the understandings around the impact of bullying, both on the individual, organisations, and the professional collective. Although discourse on the impact of workplace bullying has largely been focused on the negative impacts, there are some studies, which indicate that bullying may have positive outcomes for some. The next chapter will explore the broader context of bullying amongst hospital- based doctors, including media portrayal, legal context and economic influence, as well as examining the various theories around the multi-causal nature of workplace bullying.

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Chapter 3. Context and multi-causality of workplace bullying

This chapter explores the current research, which illuminates the multi-causal nature of workplace bullying, as well as the broader context in which it occurs. Specifically, Chapter Three unpacks the organisational contribution, the job or actual task contribution, communication patterns in healthcare and amongst doctors, and hostile behaviours, as well as contribution of generation to bullying in medicine. The contribution of medical training, and the enculturation processes, to workplace bullying will also be explored, as will the relevant professional and organisational guidelines and codes of conduct. The broader economic influence on workplace bullying, and any wider community influence on bullying and the medical profession is also unpacked. Any influence the media might have on bullying within the medical profession, the current Victorian and Australian legal and regulatory context, as well as current considerations around individual contribution to workplace bullying, inclusive of bio- psychosocial contribution, biology, and influence of age and experience on bullying targets. Understandings of who currently is to perpetrate bullying, and perception of individual contribution to bullying amongst doctors will also be elucidated. Finally, this chapter illuminates both gaps in current workplace bullying knowledge, as well as the methods used in relatable workplace bullying literature. Workplace bullying does not occur within a contextual vacuum. There are legal, organisational, professional, individual, economic, and societal factors that influence the , perpetuation, conceptualisation and experience of, bullying within the workplace. While this research predominantly focuses on any professional and organisational influences on medical student perception and experience of workplace bullying, a clearer understanding of all other impacting factors surrounding the bullying behaviours will, in turn, contribute to an increased understanding of the phenomenon; its antecedents, perpetuators, and impacts. Significantly, an enhanced understanding of the phenomenon itself provides vital context to the research questions. It is reasonable to extrapolate that the influences surrounding workplace bullying may well impact on the perceptions and experiences that medical students have on the issue. This chapter explores the multi-dimensional context of bullying behaviours amongst hospital-based

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physicians, as well as the applicable theories surrounding the multi-causality of workplace bullying. It contains a collection of what relevant current research, with its associated literature, suggests are the main contributing factors to workplace bullying. Within the articles more or less emphasis is placed on individual, organisational, or social/cultural antecedents according to how each author conceptualises the causes of workplace bullying.

3.1. Organisational contribution to workplace bullying

There is considerable research that indicates the organisation can contribute to, or is a correlating factor in workplace bullying. In her 2003 article, Salin concentrates on the multiple organisational antecedents of workplace bullying (Salin, 2003). By synthesising existing literature and developing a model to explain how each organisational structure and process contributes to workplace bullying, Salin attempts to clarify why and how certain workplace processes facilitate bullying behaviours (Salin, 2003). Salin suggests that there are three organisational areas in particular that facilitate continued workplace bullying (Salin, 2003). The first of these is, ‘ structures and processes’, such as a perceived power imbalance between perpetrator and victim, or low perceived costs, where the bully feels that the , risk or cost of the bullying behaviour is minimal (Salin, 2003). It is also possible that the organisation may have a permissive or unspoken culture of acceptance or tolerance of workplace bullying. Salin’s second condition is a ‘motivating structure or process’ within the organisation; for example, a workplace which is highly competitive, may inadvertently encourage bullying amongst colleagues who are attempting to secure a particular rank or title, which may come with increased prestige or income attached to it. Social learning theory can be used to conclude that if one employee is rewarded for such ‘cut-throat’ behaviour, then others will follow (Salin, 2003). The third condition that Salin discusses is ‘precipitating processes or triggers’ (Salin, 2003). These ‘precipitating’ organisational changes, often act as the trigger for bullying behaviours, and include restructuring and downsizing, which in turn can lead to increased and and decreased job stability and security (Salin, 2003). A study by Baillen, Neyens, De Witte, and De Cuper concludes that the link between organisational changes and workplace bullying is precipitated by job insecurity, and poor role definition (Baillen et al., 2009).

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Findings from Rutherford and Rissel’s research support Salin’s first condition, suggesting that workplace culture can indeed “normalize intimidatory behaviour” (Rutherford & Rissel, 2004, p. 67). In respect to Salin’s second condition, one researcher exploring the highly competitive nature of medical training, suggests that not only is competition amongst students and junior professionals du rigour, such unfettered competition also has the additional serious consequence of having potentially deleterious consequences for patients (Mino, 2006). Mino gives the example of medical training in France, where the first year students sit an exam, which only 10% roughly pass; this early phase is then followed by two more stages of exceedingly competitive training (Mino, 2006). In Australia medical training can be just as competitive, with equally adverse outcome according to the 2008 Australian Medical Association (AMA) ‘Survey Report on Health and Wellbeing’ (AMA, 2008). The third condition proposed by Salin, of precipitating processes or changes that may trigger bullying, is supported by an article proposing that some of the bullying behaviours witnessed recently in Australia amongst hospital-based doctors, may be triggered by a loss of status, which has been precipitated by the increased presence and power of non-medical regulatory bodies, interdisciplinary , and consumer expectation (Ivory, 2015). Extending this theory on organisational causes, and applying it to medical students situated within a hospital placement, time pressure, coupled with the long hours, high workloads and intense competition, have all been forwarded as contributory to escalating stress and perception of behaviours as hostile, and abusive in nature (Rees & Monrouxe, 2011; Gan & Snell, 2014; Ivory, 2015). While no literature can be located which thoroughly evaluates the impact of rotations on workplace bullying amongst medical staff, the AMA does suggest unpredictable schedules and workplace rosters increase stress and burnout in junior doctors (AMA, 2008). In turn, this increased stress, workplace pressures, and burnout, increases the likelihood of interpersonal conflict and bullying (Paice, Rutter, Wetherall, Winder & McCanus, 2002; Bowling & Beehr, 2006; Hauge, Skogstad & Einarsen, 2007).

3.2. Job or task contribution to workplace bullying

Another factor, which is thought to contribute to bullying in the workplace, are actual tasks associated with the job. Whilst there are substantial amounts of literature, based on

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both commentary and empirical research, outlining the challenging working conditions of medical students and doctors (Daly & Willcock, 2002; Paice et al., 2002; Riley, 2004; Cheema, Ahmad, Naqvi, Giri & Kallaperumal, 2005; Askew et al., 2012; Dwyer, Morley, Reid & Angelatos, 2011; Hills, Joyce & Humphries, 2011; Cook Vineet, Rasinski, Curlin & Yoon, 2014; AMA, 2008; RACS, 2015a), it is only by applying theoretical frameworks found in workplace bullying literature, that a better understanding can be gleaned of any link between the workplace stressors, and the high risk of exposure to bullying for medical students and doctors. In turn those high levels of exposure to abrasive behaviours may ultimately influence the way medical students’ perceive or observe, conceptualise, define and experience workplace bullying. The frustration-aggression, stressor- and social-interactionist perspectives all aim to clarify how stressful work environments can increase the likelihood of bullying (Hauge et al., 2007). These theoretical frameworks are not only useful in helping to identify the centrality of workplace norms, and the perceived control of a work environment, but they can also help understandings of how ones interaction and reaction to the workplace context, can contribute to bullying within the workplace (Hauge et al., 2007). However, what the study by Hauge cannot do, is help illuminate the individual’s subjective experience of that stressful workplace, or to clarify whether the stress is due to the bullying, or whether the bullying is a reaction to a stressed individual, or indeed a stressed environment. This research seeks to explore individual medical student experiences and perceptions of bullying amongst doctors in hospitals. Quantifiable measurement will not always achieve greater understanding of the relationship between the individual and their conceptualisation of experience. In terms of job task contribution to workplace bullying, Hoschschield suggests that those who work in the social and health field, may be more at risk of bullying because of a higher level of personal and emotive involvement, thereby increasing exposure of your personal details and psychological , as well as increasing your risk of personal attacks (cited in Zapf, 2011). Significant amounts of individual responsibility at an early point in their career increase workplace stress levels, and reduces competency rates, thereby increasing vulnerability to, and experiences of workplace (Dollard et al., 2007). In a United Kingdom study of junior doctors they identify that 33.6% of reported stressful incidents are when the doctors have to deal with a situation that is beyond their professional experience or capability (Paice, Aitken,Houghton & Firth-Cozens, 2004). Similarly, the Australian

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Medical Association survey report on junior doctor health and wellbeing advises that the combination of enormous responsibility, stress, and high is often juxtaposed with the of having “limited power to influence or change situations” (AMA, 2008, p. 12), potentially contributing to the junior doctor’s stress and frustration. Throughout a medical doctor’s career, from junior doctor through to senior physician or consultant, physicians often remain responsible for the life or death of other people, and are often considered accountable for the quality of another’s life. What doctors ‘do’ potentially make them unique bullying targets, or perpetrators, as they work in a high stress, emotionally charged, pressured environment, often under challenging working conditions (Riley, 2004). In terms of individual ethical and legal responsibility for a patient, the culpability often rests with that doctor (Finlay, Stewart & Parker, 2013). As medical researcher and academic Mino suggests, “In the end, you alone are responsible for your patient and you rely on yourself” (Mino, 2006, p. 207). A 2013 ‘National Mental Health Survey of Doctors and Medical Students Survey’, conducted for the organisation, beyondblue, reports that level of ‘responsibility at work’ contributes to stress levels for 20.8% of the respondents (beyondblue, 2013, p. 68), with rates of stress being higher in certain specialties such as paediatrics, obstetrics and gynaecology (beyondblue, 2013, p. 144). More than many other professions, doctors are often performing in highly time sensitive matters, and time is of acute importance to what they do (Riley, 2004). Not only are the tasks that doctors perform often time sensitive (just think of the aptly named Accident and Emergency Department), much of their performance as a unit and, or a hospital, is measured by time. The less time spent on a patient, the more ‘efficient’ the hospital is deemed to be (National Health Performance Authority, 2015). Moreover, government funding for a hospital can depend on the hospital’s performance in treating patients in a ‘time efficient’ manner (Victorian Department of Health, 2015). Although the repercussions for not addressing a patient within a given time frame can be life threatening to the patient, it is argued that time pressure may indirectly impact bullying by adding pressure and diminishing any opportunity to resolve conflicts (Salin & Hoel, 2011). In addition, from a physical space perspective, having to share instruments or equipment, in crowded, noisy or otherwise unpleasant spaces have also all been shown to potentially increase levels of workplace bullying (Salin & Hoel, 2011). Given the high stakes nature of many of the tasks that doctors carry out, there are

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a number of opportunities for formal reporting of sub-par professional behaviour or performance. It is, however noted that even this process has been usurped as a tool of bullying, with considerable submissions being made in the recent Senate inquiry outlining ‘vexatious complaints’ that have been made against doctors either internally within the hospital or healthcare institution, or through the formal channels of the Australian Health Practitioners Agency (AHPRA) (Commonwealth of Australia, 2016). It is further noted in the Senate report that vexatious medical process complaints are often submitted in direct retaliation for the targets own initial formal complaints of bullying or harassment (Commonwealth of Australia, 2016). Another job related factor, which may contribute to the incidence and acceptance of bullying, is the frequent use of humour amongst doctors (Wear, Aultman, Varley & Zarconi, 2006). Frequent use of humour in the workplace can sometimes be accepted as part of a culture norm, but can also equally as easily cross lines into offensive behaviour (Einarsen, Hoel, Zapf & Cooper 2011, Supanich, 2006) and be defined as bullying. Theories on the evolution of humour suggest that it may have developed as a tool of communication with other group members, signalling that built up tension can be released, and that, in fact any perceived threat could be considered a ‘false alarm’ (Howe, 2002). Furthermore, it has been proposed that a cognitive function of humour and laughter is that of a defence mechanism, using jokes to “trivialize what would otherwise be genuinely disturbing anomalies” suggests the possibility that have internalised their own personal ‘false alarm’ system (Ramachandran, 1998). There are a number of theories that indicate a possible social advantage for those who demonstrate what is considered a culturally appropriate sense of humour (Howe, 2002; Martin, 2008). Extrapolation of this theory could suggest that if hostile or abrasive, bullying humours are an accepted part of a particular workplace or institutional culture; this could be indicative of the kinds of actual processes and behaviour being tolerated. As suggested in the RACS Guidelines to Bullying and Harassment (RACS, 2014), dismissing hostile or bullying behaviours as ‘just a joke’ is never acceptable. Additionally, Salin and Hoel suggest that “humiliating jokes, surprises, and insults” can sometimes become part of an unhealthy workplace socialisation process (Salin & Hoel, 2011, p. 231).

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3.3. Communication in medicine

It is possible that communication amongst employees, specifically hospital-based doctors, may influence incidents of workplace bullying. Effective communication in medicine is of critical importance, in terms of both the improvement of patient outcomes and the prevention of medical errors (Rider & Keefer, 2006; Salmon & Young, 2011) it is also broadly accepted that “good communication underpins every aspect of good medical practice” (Medical Board of Australia, 2014, p. 5). It is therefore remarkable that currently there are such limited studies, which explicitly explore communication patterns amongst doctors as a collective, and linkages between that communication and bullying behaviours. There is however literature on inter- professional relationships in healthcare, which flag the duel challenges and importance of collaborative practice amongst multiple health professionals (Barker & Oandasan, 2005; Hall, 2005; Nugus, Greenfield, Travaglia, Westbrook & Braithwaite, 2010; Gittell, Godfrey & Thistlewaite, 2012; Thistlewaite, 2012), and there are studies that examine particular flashpoints or communicative intersections such as consultancies and clinical handover (Hewett, Watson, Gallois, Ward & Legget, 2009; Eggins & Slade, 2012; Kessler, Chan, Loeb & Malka, 2013). Some research on clinical handovers and consultations suggest that clear communication amongst all health professionals is vital, and while tools such as ISBAR (Introduce, Situation, Background, Assessment & Recommendations) or I-PASS (Illness severity, Patient summary, Action, Situation, Synthesis) can be effective in improving patient care, inter-physician communication skills training is needed, as is the of contextual influence, in fully understanding the dynamics of communication in healthcare (Hewett et al., 2009; Eggins & Slade, 2012). The study by Hewett et al., which is unpacked further on in this section, highlights both the strong sense of doctors’ professional and disciplinary memberships, as well as the conflict between the groups that can arise over issues of task content and organisational process (Hewett et al., 2009). Increasingly there are also studies, which seek to clarify patterns of use of new communication technologies in healthcare, such as the increased reliance on emails, and the use of text messages amongst doctors (Wyber, Khashram, Donnell & Myer- Rochow, 2013; Malka, Kessler, Abraham, Emmet & Wilbur, 2015). The one survey study that does combine dual exploration of communication and bullying, investigates the impact of workplace cyberbullying on trainee doctors (Farley, Coyne, Sprigg, Axtell

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& Subramanian, 2015). While the Farley et al. study is able to establish prevalence of cyberbullying at work, and record a perceived negative impact on both trainee doctors’ job satisfaction and mental strain, the electronic communication investigated is not exclusively between doctors, nor did it aim to capture and elucidate patterns of collective communication. The study did however find that 35.6% of the cyberbullying is perpetrated by other trainee doctors, which is striking given offline bullying of medical students and trainee doctors is usually perpetrated by senior staff (Farley et al., 2015). Patterns of electronic communication in a number of other studies also report a level of formality when communicating upwards. The research by Postmes, Spears and Lea, notes that emails sent to individuals of higher organisational status display a significant increase in social and formality (Postmes et al., 2000), which is consistent with results from the New Zealand study exploring use of SMS texting amongst doctors within a hospital. The study of 288 hospital-based doctors found that texting follows lines of organisational and professional hierarchy, with most doctors only texting amongst their own status level, i.e. residents texting residents, notably interns did not text consultants, nor were they texted by, consultants (Wyber et al., 2013). Moreover, a study of email communications amongst surgical residents and fellows found that a lack of formal greeting, or the use of a novel font were amongst the communication features that elicited negative responses, such as thinking poorly of the sender, and or delaying their response time (Resendes, Ramanan, Park, Petrisor & Bhandari, 2012). In terms of studies on communication in healthcare, there are still relatively limited studies on the way doctors communicate with each other, or conceptualise how they have learnt communication skills. Also research on how programs aiming to facilitate improved communication skills with their medical colleagues remain relatively uncommon (Hewett et al., 2009; Kessler et al., 2013; Mendick, Young, Holcombe & Salmon, 2015). Further salient insights extracted from the communication literature, include the Australian study which uses data from in-depth interviews and inpatient medical records, and explores communication exchanges between hospital- based doctors from different medical specialties, revealing that intergroup conflict or tensions has a significant influence on communication patterns and communication efficacy for patients (Hewett et al., 2009). Moreover, the research literature notes that issues of role responsibility or ambiguity, over areas such as informed consent, admission and accommodation contribute to communicative tensions amongst the

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doctors, which is congruent with other broader findings on antecedents of bullying (Baillien et al., 2009; Victorian Auditor General, 2016). Also of relevance in the literature on communication in medicine, is the identification of “strong normalising statements from senior staff instructing junior doctors not to take direction from doctors in another specialty group” (Hewett et al., 2009, p. 1737), illustrating how the dynamics of structural and procedural hierarchy in communication can contribute to moments of workplace conflict amongst the doctors.

3.4. The intergenerational legacy of bullying behaviours

There are multiple studies reporting that when it comes to how medical students and junior doctors learn bullying and harassing behaviours, that intergenerational legacy play a part by modelling these behaviours from each generation of doctors. In the Canadian study by Gan & Snell, it is suggested that there is an “ of medicine” which is characterised by t he acceptance of abrasive interactions or behaviours (Gan & Snell, 2014, p. 612). Within this organisational culture of medicine, medical students and junior doctors may well feel unable to safely voice their concerns regarding bullying or hostile behaviours or practices. In the submission to the Expert Advisory Group (EAG) on ‘Discrimination, bullying and sexual harassment advising the Royal Australasian College of Surgeons’, the Australian Medical Association (AMA) suggests “the working environment in public hospitals, with a culture of bullying and harassment that can normalise such behaviour” (Owler, 2015, p. 2) contributes to the perpetuation of abrasive behaviours. For decades, medical schools worldwide have reported a high prevalence of mistreatment of medical students, often by those further up on the hierarchical scale. In 1998, one medical academic labelled the phenomenon of cyclical abuse amongst doctors as a “transgenerational legacy” (Kassebaum & Cutler, 1998, p. 1149). Kassebaum and Cutler’s article unpacks what fosters and constitutes this legacy, as well as exploring measures, including those which had been taken since 1990, and those which could be further implemented, to rectify the problem of medical student abuse (Kassebaum & Cutler, 1998). Kassebaum and Cutler also note that when using data collected from the Association of American Medical Colleges (AAMC), very little had changed during the 1990s, with the rate of general reported mistreatment of medical students declining from “40.8% to 38.3%” (Kassebaum and Cutler, 1998, p. 1152). Remarkably, an editorial in

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the American Medical Association online Journal of Ethics, the ‘Virtual Mentor’, notes that results of the 2013 AAMC survey indicates that medical student mistreatment rates are now actually sitting at 47.1% (Major, 2014, p155). However, none of the surveys or articles indicates why there might have been a reported increase since the 1990s, but they do suggest that transgenerational legacy could play a role in the perpetuation of bullying behaviours amongst doctors. The intergenerational nature of bullying has been particularly noticeable within the medical specialty of surgery, with the Royal Australasian College of Surgeons (RACS), recently acknowledging the intergenerational harassment and abuse that female doctors, medical students and junior clinicians in particular, have suffered often at the hands of older male surgeons. (RACS, 2015a; RACS, 2015c).

3.5. The contribution of medical training and enculturation processes to workplace bullying

I will impart a knowledge of the Art to my own sons, and those of my , and to disciples bound by a stipulation and oath according to the law of medicine, but to none others – The Oath of Hippocrates

Aspects of medical training and the process of enculturation into the profession of medicine are sometimes nominated as a contributing factor to bullying amongst doctors. Clinical training often takes place in a hospital setting where one or two doctors can make, or significantly impact, career trajectory or direction for the junior doctors. Such an impact can last the career lifetime of the doctor, and a 2002 study of British junior doctors suggests “the relationship between the doctor in training and the supervising consultant is central to the learning experience, and can have a lasting impact on (their) career decisions” (Paice et al., 2002, p. 63). In a further article, Paice, writing with Smith, contends that for doctors, “demands often exceed capacity”, and that overload, burnout and stress all contribute to the suboptimal performance and behaviours of clinical supervisors (Paice & Smith, 2009, p. 13). When overlaid with environmental stressors, and the power differential inherent in the medical profession’s mode, a ‘’ can see the abused perpetuating the abuse when they reach higher levels of authority (Owler, 2015, p. 9). Despite these factors, it is clear that additional duties in the form of supervision, mentoring, teaching and assessing of medical students and junior doctors are all

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expected roles for experienced clinicians. In the Medical Board of Australia’s, Code of conduct for doctors in Australia, the board outlines that teaching activities are part of “good medical practice”, and that doctors are expected to treat “your students with respect and patience” (Medical Board of Australia, 2014, p. 23). Furthermore, in Section 10 of The Code of conduct for Australian Doctors, it suggests that a ‘good doctor’ creates opportunities for leaning, and nurtures the future medical workforce (Medical Board of Australia, 2014) Referring back to the 2015 study by Scott, Caldwell, Barnes and Barrett, the research not only highlights a high rate of participating medical students having experienced teaching by humiliation but the recent Australian study also reports a significant difference in medical student experience between the teaching in adult medicine and paediatric, with only 28.8% of medical students in paediatrics experiencing teaching by humiliation and mistreatment, and 45.1% witnessing it (Scott et al., 2015). The research defines teaching by humiliation as inclusive of experiencing or witnessing medical or surgical teaching staff asking students questions in intimidating ways, being belittled, shouted or yelled at, or cursed and sworn at (Scott et al., 2015). A comparison study between bullying and harassment of medical and nursing students flags that medical students report being bullied and belittled mainly by clinicians in charge of teaching them, which was different from the nursing students experiences, who reported experiencing bullying from a wider range of ‘perpetrators’ inclusive of fellow nurses, physicians, healthcare assistants and patients (Timm, 2014). Moreover, medical students are described as less likely to report or challenge the bullying behaviours, which the author surmises is a result of socialisation of medical students into a professional culture which accepts bullying behaviours as a tolerated, normative feature (Timm, 2014). Similar to the observations cited by Salin (Salin, 2003), other researchers also suggest certain motivating structure within an organisation, such as extreme competition for achievement, promotions, scholarships or coveted limited positions within certain medical specialities as a possible reason for workplace bullying (Tuckey, Dollard, Hosking & Winefield, 2009). Dovetailing with this theory is the considerable pressure for trainee and junior doctors to put in extra hours, and in some specialities to be seen to arrive early and leave work late, even if the work has been done already (Dickson, 2005). Similarly, the Australian Medical Association Survey on junior doctor health and

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wellbeing highlights this, suggesting that “the culture of the medical profession has traditionally expected junior doctors to deal with heavy responsibilities” such as demanding workload, high expectations of achievement both academic and clinical, as well as working in an emotionally charged and draining work environment (AMA, 2008, p. 9). A report from Australian research which interviews 22 medical practitioners, outlines a number of different types of enculturation processes that doctors encounter (Gordon, Markham, Lipworth, Kerridge & Little, 2012). The first enculturation process is described as ‘absorption’, where graduate doctors absorbed, by implicit incorporation, the dominate organisational or institutional “cultural norms, practices and beliefs”, and ‘assimilation’ which is explained as “a deliberative process which involves the choice to adopt or reject” institutional, or organisational norms (Gordon et al., 2012, p. 897). The research also documents a process of ‘professional formation’, which is explained as a practice that sees new graduates and junior doctors engaging in continual “deliberative moral and ” (Gordon et al., 2012, p. 899). A body of research and its associated literature outlines different perspectives on the curriculum of enculturation into the medical profession. This literature provides valuable insight into the kind of professional and institutional context in which medical students are situated when they are conceptualising and experiencing bullying amongst hospital-based doctors. A study of 36 medical students report on a professional culture that is characterised by “competition rather than cooperation” (Lempp & Seale, 2004, p. 772), as well as a rigid hierarchy, which is typified by incidents of academic humiliation (Lempp & Seale, 2004). Lempp and Seale’s findings dovetail with other studies on medical student enculturation which report that despite being taught a formal curriculum, which encompasses values such as respect, honour, integrity and excellence, students instead are conflicted when they have to operate within an environment “where power and personality are more important than patients or than explicitly “professional” behaviour (Brainard & Brislen, 2007, p. 1011).

3.6. Professional and organisational guidelines and codes of conduct

In this section, some of the professional charters, and organisational codes of conduct that help define and redress workplace bullying are overviewed. Organisational and

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professional codes, guidelines or reported regulations, may influence how hospital- based doctors and medical students experience, perceive, conceptualise and define bullying behaviours. Furthermore, a lack of effective, visible professional and organisational guidelines, regulations and codes of conduct may well also be construed as a barrier to redressing the issue of bullying within medicine (RACS, 2015b).

Professional codes

In the Australian context, the Australian Medical Association (AMA) offers this definition of medical professionalism, “medical professionalism embodies the values and skills that the profession and society expects of doctors. Through adherence to medical professionalism, doctors fulfil their duties to patients and the wider public” (AMA, 2010, Section 3.1). The Australian Medical Association lists a core set of professional values that they expect doctors to adhere to, including; respect, trust, compassion, altruism, integrity, justice, , and protection of confidentiality, leadership, and collegiality (AMA, 2010). It is important to note that doctors have a core set of professional principles to which they are expected to adhere (AMA, 2010; Medical Board of Australia, 2014). These broad professional principles lay the contextual foundation on which specialised colleges, organisations, and other governing bodies build upon. There are a number of codes and position statements that exist for the regulation of physician behaviours. These regulations encompass doctor behaviour amongst colleagues, within a broader social context, and within the patient-doctor interaction. In Australia, these guidelines or codes are produced by a number of different professional and regulatory bodies such as the Australian Medical Association, Australian Medical Students Association, Medical Board of Australia, and the Australian Medical Council. Specialist medical colleges such as Royal Australasian College of Surgeons, Royal Australasian College of Physicians, or the Royal Australasian College of General Practice also produce guidelines governing member behaviours. Many of these explicit, documented guidelines include: respect for medical colleagues, effective and clear communication, and provision of positive role modelling behaviour for doctors and other health professionals (AMA, 2010; RACS, 2016). Some of the guidelines specifically address expected behaviour around workplace bullying. The Medical Board of Australia released a document entitled, Good medical practice: A

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code of conduct for doctors in Australia which is issued under s39 of the Health Practitioner Regulation National Law Act (2009) and which clearly states under Section 4.4 (44.6) that doctors are required to understand “the nature and consequences of bullying and harassment, and seek to eliminate such behaviour in the workplace” (Medical Board of Australia,2014 p. 9). Moreover, the Royal Australasian College of Surgeons in their Code of Conduct for members, asserts that a surgeon will “seek to eradicate bullying or harassment from the workplace” (RACS, 2009, p. 10), the updated version of the code has evolved suggesting that a surgeon will “not discriminate against, bully, or sexually harass another healthcare professional or other person” (RACS, 2016, p. 10). In 2009 Section 10 of the RACS Code makes an explicit connection between teaching, mentoring and professional hierarchy suggesting that it is a breach of the code to “engage in behaviour that involves bullying or harassment as a result of the surgeon’s senior position” (RACS, 2009, p. 20), and in 2016, after the media attention and the formation of the RACS Expert Advisory Group on discrimination, harassment and bullying in medicine, that same section expanded in content and evolved in language to include phrases such as “ensure Trainees and IMGs (International Medical Graduates) are safe in the workplace”, “not make prejudicial decisions or judgments…”, and “give honest and respectful feedback..” (RACS, 2016, p. 16). In 2009, the Australian Medical Association released a position statement entitled Workplace bullying and harassment. The aim of the statement is to provide a guide for doctors, to help identify and manage workplace bullying, raise awareness and reduce episodes of bullying, as well as helping the profession to eliminate the perpetuation of bullying (AMA, 2009). The statement acknowledges the negative impact of workplace bullying, and suggests that because of their high workloads, training schedules, and social, geographical and professional isolation, junior doctors may be “more susceptible to the effects of bullying” (AMA, 2009, p. 2). Interestingly this position statement does not suggest junior doctors are more likely to be targeted, but rather that the effects of bullying may be felt more keenly. However, the 2015 update of the AMA position statement expands on this, suggesting that medical students, junior doctors, female doctors and international medical graduates are ‘targeted’ rather than just being ‘more susceptible’ (AMA, 2009). The position statement continues to give the example of academic humiliation and include other factors, which increase the risk of bullying and harassment as “work stressors, leadership styles, systems of work, work relationships and workforce characteristics”

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(AMA, 2015, p. 1). The changes documented above give an indication of incremental shifts made by professional medical bodies both in the level of understanding of bullying in medicine, and a firm establishment of a reduced willingness to tolerate the behaviours. Internationally, there are similar codes of conduct for doctors. An example of this would be the American College of Physician Executives, which has behavioural codes designed to diminish disruptive or abusive physicians (Weber, 2004), or on a broader scale, the American Medical Association’s Code of Medical Ethics, outlines standards of physician conduct (American Medical Association, 2001). In a similar fashion to the documented changes, to the Australian Medical Associations’ position on bullying and harassment, the Royal Australasian College of Surgeons (RACS) has recently invested significantly in the research and publication of material for its members, on harassment and bullying in the specialty of surgery. In 2009, RACS had published a guide called Bullying and harassment: Recognition, avoidance and management (RACS, 2009). This particularly comprehensive guidebook acknowledged that bullying and harassment by surgeons could lead many talented medical students to reject a career in surgery (RACS, 2009). It outlined definitions, negative outcomes, working examples of bullying behaviours and scenarios, and gives resolution options to both targets of bullying and perpetrators (RACS, 2009). The Royal Australasian College of Surgeons produced an updated version of the guidelines in January 2014. Furthermore, the Australian Medical Association in response to a call for submissions to the 2015 RACS enquiry into discrimination, bullying and sexual harassment in the practice of surgery, gave a comprehensive response to questions posited by the surgical college. The document acknowledges the prevalence and negative outcomes of workplace bullying, reporting that “discrimination, bullying and sexual harassment persist in the health sector, including in the practice of surgery, despite clear evidence that these behaviours jeopardise patient safety and negatively impact on victims” (Owler, 2015, p. 2). Moreover the submission outlines the entrenched, long-standing culture of harassment and bullying, as well as the ingrained resistance to report these abrasive behaviours. In this document, the AMA makes it clear that there is never a time when bullying, discrimination and harassment are professionally acceptable (Owler, 2015). Since those papers were produced, RACS has released a further research report in an attempt to increase its understanding of the phenomenon, coupled with a multi-media

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awareness campaign, and mandatory professional development modules, exploring concepts of respect, and inclusion. Most of the medical regulations and codes have consequences attached if doctors are found to have failed to comply. As the Medical Board of Australia suggests in their 2014 Code of conduct, “If your professional conduct varies significantly from this standard, you should be prepared to explain and justify your decisions and actions. Serious or repeated failure to meet these standards may have consequences for your medical registration” (Medical Board of Australia, 2014, p. 4). On a broader scale, there are also some recently implemented legal options afforded to Australian employees who are affected by workplace bullying. The relevant legislations will be discussed in greater detail later in this document.

Organisational codes relating to bullying and harassment in hospitals

There is a significant amount of overlap between some of the professional codes and the organisational codes; however, organisational guidelines appear to have a wider focus, concentrating instead on how all employee behaviour impacts the organisation, its patients, and the community in which it is based. The Melbourne Health code of conduct (2011) suggests, “the actions of each and every public sector employee, no matter what their role, will shape the way their organisation and the sector as a whole are perceived” (Melbourne Health, 2011, p. 6). Many of the codes of conduct and employee guidelines use broader legislative Acts as a foundation on which to build their own policies. The Melbourne Health code of conduct (2011) does this, citing the Code of conduct for Victorian public sector employees (2007), Public Administration Act 2004 and the Health Services Act 1988 as key influences to its own organisational policy. The Melbourne Health code of conduct mentions values and behaviours of staff that are both acceptable and unacceptable. Bullying and intimidation are at the top of the unacceptable list of behaviours; furthermore the Employee Code states that employees must “ensure freedom from discrimination, harassment and bullying at all times” (Melbourne Health, 2011, p. 8). In its Workplace bullying statement, Melbourne Health espouses values of caring, respect, unity, discovery, integrity, and makes explicit its stance on bullying and other hostile or abrasive behaviours, furthermore it has a very clear definition of bullying drawn from a range of objective and operationalised legislations and policies (Melbourne Health, 2012).

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However, it is also worth remembering the previously discussed research articles, which have outlined an alternative, hidden curriculum of professional medical values and expected and accepted codes of conduct. The results from the Lempp study suggest that there are six components to the hidden agenda, which, they argue are embedded in the medical education processes, however, they are also arguably played out in medical students’ clinical placement settings. The components include, “loss of idealism, adoption of a ‘ritualised professional identity, emotional neutralisation, change of ethical integrity, acceptance of hierarchy and the learning of less formal aspects of ‘good doctoring’” (Lempp & Seale, 2004, p. 770).

3.7. Broader economic contribution

One argument for increased bullying behaviours is that in the context of a tough economic climate, the GFC and globalisation, hyper-aggressive professionals are being rewarded in the workplace and in society (Namie, 2007). A 2007 study by Ferris, Zinko, Brouer, Buckley and Harvey, suggests that some tacitly encourage ‘strategic bullying’ thereby ridding the organisation of individuals who are perceived as unproductive, or a burden (Ferris et al., 2007). Arguably hospital-based doctors are working in a competitive, demanding environment where they are being judged on unforgiving Key Performance Indicators (KPI), including high levels of patient throughput. Formed in 2011, under the National Health Reform Act (2011), Australia’s National Health Performance Authority reports on hospital efficiency. The Authority defines efficiency as a hospital “able to deliver more services while consuming fewer resources” (National Health Performance Authority, 2015, p. 1). Adding to staff workplace pressure and stress, hospital units may be fiscally penalised if their targets are not met (Victorian Department of Health, 2015). Furthermore, current Federal Government cuts to hospitals mean, “public hospitals are struggling to cope with increasing patient demand and shrinking budgets” (Rollins, 2015, p. 9). One article that explores the unintended consequences of performance measurement in the British healthcare system actually specifies bullying, suggesting that “bullying can occur when uncomfortable levels of pressure and on staff are brought about by a demanding climate” (Mannion & Braithwaite, 2012, p. 572). The purported objective of the article by Mannion & Braithwaite is the production of a ‘cautionary tale’ for the Australian healthcare system, highlighting the unintended

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dysfunctional consequences of UK National Health Service performance measurement (Mannion & Braithwaite, 2012).

3.8. Community influence on bullying and the medical profession

Another contextual factor, which has the potential to influence the behaviour of a doctor, is public opinion and expectation of physicians. Perhaps stemming from an historic expectation for doctors to practice good personal self-awareness, or self- regulation (Breen, Cordner, Thomson & Plueckhahn, 2010), and indeed rooted in the Oath of Hippocrates is the declaration that as a doctor, one will “with purity and with holiness I will pass my life and practice my Art” (Hippocrates, 2008, p. 1). The public has relatively high expectations of medical doctors’ values, behaviours and actions, and a report based on the United Kingdom study of 89 patients found that there is an assumption that doctors are of “a relatively good character”, with one participant suggesting “…the expectation of the general public that doctors, surgeons, police officers, school teachers, they’ve got to be that little bit sort of better, or cleaner than anybody else” (Gill, Bridges & Nicholls, 2012, p. 12). It is conceivable that these high level expectations may in turn put additional pressure, stress or burden on doctors to perform to an elevated level of competence, sometimes beyond what many other professions may experience. The Good medical practice code of conduct outlines, “patients trust their doctors because they believe that, in addition to being competent, their doctor will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion” (Medical Board of Australia, 2014, p. 5). It is also suggested that good doctors will have the following virtues; trustworthiness, compassion, prudence, justice, courage, temperance, integrity and self- effacement (Breen et al., 2010). In Australia, the recent media attention, on the issue of bullying amongst medical trainees has highlighted, not only the high prevalence of bullying amongst doctors, but also the public reaction of outrage or scandal. This level of interest and outrage is perhaps reflecting the public that doctors should be held accountable to higher standard of morality, scruples, or goodness of character. Conversely this social perception of infallibility may give some doctors a false sense of diminished accountability, thereby nurturing a notion of being exempt from the social norms of civility and reciprocity. A number of studies have shown that violation of the

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social norms of reciprocity or justice have been linked to an increase in workplace aggression and (Neuman & Baron, 2011). These social factors may influence prevalence rates or frequency of hostile workplace relations amongst doctors. They may also influence the nature of the hostile interaction. Societal expectations of physicians mean they have a high status standing within the community, which may mean that a lot is expected of them socially and professionally, but conversely it could be argued that doctors expect that they can get away with questionable behaviours. Interestingly, Dr Kimberley Ivory recently suggests that the increasing disconnect between doctors expectations of being relatively untouchable and “on top of the pyramid”, and the publics escalating demands for involvement, input and physician accountability, has contributed to “some of the bad behaviour we see symptomatic of a profession struggling to adapt to lost status” (Ivory, 2015, p. 564). There are currently no known studies that explore a correlation to community expectations on doctors, and public perceptions of bullying amongst doctors.

3.9. Media influence on bullying and the medical profession

While difficult to quantify any influence that mainstream media may have on causality, prevalence and perception of bullying amongst and medical students and doctors, its potential influence over their perception, conceptualisation and experience of bullying behaviours cannot be overlooked. As previously mentioned, there has been a recent proliferation of media attention on the issue of bullying amongst doctors, with printed articles sporting headlines such as; “Three Victorian psychiatrists’ deaths raise questions over ‘intense’ training program” (Medew, 2015d), “Medical students under pressure amid reports of bullying in Australian hospitals” (Medew 2015a), “Revealed: the cost of bullying and violence in the Australian Public Service” (Towell, 2015), “Sexual harassment inquiry: senior doctors say women can also be perpetrators” (Whyte, 2015), and “Teaching by humiliation rife in hospitals, leaving juniors disheartened” (Belot, 2015). Furthermore, the Australian Broadcasting Commission’s Four Corner’s program aired in May, 2015 was entitled “At Their Mercy”, and raised the issue of bullying of junior doctors (Australian Broadcasting Commission, 2015). While high profile surgeons such as Dr Charlie Teo and Dr Gabrielle McMullin continue to speak out about the bullying and sexual harassment, medical students and

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junior doctors will undoubtedly be observing how these doctors are subsequently treated by the profession and its representing bodies. It is of consequence that the 2006 complaint made by then neurosurgery trainee Caroline Tan against neurosurgeon Mr Chris Xenos, according to media coverage, resulted in Dr Tan enduring a very public “vigorous attempt to thoroughly denigrate her character and professional competence”, and that her persistence with prosecution came “at enormous personal cost” (Hannan, 2008, www.theaustralian-com-au/news/nation/k-bill-for-sex-case/news- story/accessed23/11/09). While Xenos’ employer said at the time of the case, that no action would be taken until after the legal process had concluded, it is noteworthy that he is still employed by the same hospital network nine years after he was found guilty of sexually harassing Tan. Dr Gabrielle McMullin suggests that she had written to the Royal Australasian College of Surgeons seven years prior to the recent public debate on bullying and harassment in medicine, outlining the prevalence of sexual harassment for female trainee surgeons, and asking for advice and assistance. Dr McMullin says, “They didn’t want to know. You might think someone would phone me and say, ‘oh my goodness, this is a terrible situation. Would you like to come and talk to us about it in confidence?’ I was just a bad smell and they wanted me to go away” (Medew, September, 2015). According to one anonymous source, as the result of the media coverage on bullying and harassment amongst hospital-based doctors, internal organisational memos are regularly sent out to staff of several Victorian teaching hospitals, condemning bullying and harassment. An example of a memorandum sent out to hospital staff, in the wake of high profile media attention can be seen in Figure 3.1 below. Source: Anonymous

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Figure 3.1. Hospital staff memorandum of bullying and media attention

3.10. Australian parliamentary findings, legislation and regulatory considerations

Legislation, parliamentary outcomes and regulatory guidelines relating to bullying in the workplace are all factors, which have the potential to influence and impact doctors’ bullying behaviours.

Parliamentary investigations

Following the high level of community awareness on bullying in medicine, in 2016 the Australian Senate instructed the Community Affairs References Committee to inquire and report on a number of issues relating to medical complaints process in Australia. The first and second specific terms of reference include: (a) the prevalence of bullying and harassment in Australia’s medical profession;

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(b) any barriers, whether real or perceived, to medical practitioners reporting bullying and harassment. An earlier parliamentary investigation complete with expert and industry submissions, and subsequent report, in the form of the House of Representatives Standing Committee on Education and Employment, Workplace Bullying: We just want it to stop, October 2012, found that bullying was also pervasive, and enormously impactful in multiple industries and workplaces. In the 2016 Senate Inquiry, concerned individuals and medical professional bodies such as the Australian and New Zealand College of Anaesthetists, Royal Australian and New Zealand College of Psychiatrists, Nursing and Midwifery Board of Australia, Royal Australasian College of Surgeons and Australian Medical Association all made submissions to the Senate Inquiry. The first recommendation produced by the parliamentary investigation is outlined in the introduction chapter, and focuses on acknowledging the prevalence of, and the responsibility, and commitment of all parties, which is needed to effectively address the problem. The second recommendation suggests a recognition that the issue of bullying is one that needs to be addressed early on in the education and career of a doctor. Recommendation 2 (4.27) reports, “The committee recommends that all universities adopt a curriculum that incorporates on bullying and harassment” (Commonwealth of Australia, 2016, ix).

Australian legislation

Understanding the current Australian legal context provides increased insight, not only into the political, cultural and established authorities stance on workplace bullying behaviours, but it might also provide a broader context to what could influence medical student’s perceptions and experiences of intra-professional bullying. As outlined in section 3.5 of this chapter, under the various college Codes of Conduct, the Medical Board of Australia, and the Health Practitioner Regulation National Law Act (2009), there are possible recourses and repercussions available to doctors who have bullied, or are being bullied at work. Further to that there are a number of broader legislative and regulatory options available. Figure 3.2 outlines some of the legislative recourse existing for individuals who believe that they have been bullied in the workplace. Workplace bullying that occurs within a Victorian context differs slightly from other

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Australian states, due to the introduction of the Crimes Amendment (Bullying) Bill (2011). Colloquially known as ‘Brodie’s Law’, named after the 19-year-old waitress, Brodie Panlock who committed suicide after years of documented cruel and relentless bullying at her workplace, this is a Bill for an Act to amend the Crimes Act 1958, the Intervention Orders Act 2008 and the Personal Safety Intervention Orders Act 2010. The Victorian Act is currently the only legislation in Australia dealing with bullying, which includes the element of intent. Bullying that involves physical or ‘credible’ threat of assault is now considered a criminal offence in all Victoria. The amendment refers to the perpetrator having “the intention of causing physical or mental harm to the second person, including self-harm” part 3 6 (1) in ‘Meaning of Stalking’, it also refers to using/directing/performing abusive or offensive acts or words towards a victim. With an upsurge in research being conducted on the cause and consequence of workplace bullying, increasingly the legal definitions are being informed both by research findings, the public’s heightened awareness of the issue, and the “subsequent political context in which the legislations is introduced” (Lippel, 2010, p. 4). While there are a number of legal options available to those who can prove they have been bullied in Australian workplaces, most of them have limitations. In the article entitled ‘Workplace bullying laws in Australia: Placebo or panacea?’, the authors outline the limitations, pointing out the monetary limitations available in most Occupational Health and Safety legislation, and the fact that ‘Brodie’s Law’, can only be used address individual perpetrators of workplace bullying, rather than being able to prosecute the employers for the bullying conduct that occurred in their workplace (O’Rouke & Antioch, 2016). The authors also urge that stricter application of penalties, criminal sanctions in other Australian states, and larger uncapped monetary fines might be a more effective approach to workplace bullying than the laws currently available (O’Rourke & Antioch, 2016).

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Figure 3.2. Options for a Victorian workplace bullying claim

Source: Ryan Carlisle Thomas Solicitors, Submission 106, p. 8, as quoted in House of Representatives Standing Committee on Education and Employment (2012), as reproduced in the Workplace Relations Framework, Productivity Commission Report, August, 2015.

Sections 6-4B of the Fair Work Act 2009 (Cth.) are anti-bullying amendments introduced in January 2014. This section of the Act give the Fair Work Commission the authority to act as a “mediator, conciliator or as a last resort, adjudicator” (Australian Government, Workplace Relations Framework, 2015, p. 268). In cases of workplace bullying, the Fair Work Commission can make any order it considers appropriate to stop the workplace bullying from occurring. While the Fair Work Act (FWA) cannot provide compensation to the worker, there are other avenues a worker could pursues, such as through worker’s compensations, or workplace health and safety legislation. An example of such legislation would be the Victorian Occupational Health and Safety Act 2004. Although it worthwhile noting that each State has slightly different Acts with differing compensations available, for example, in South Australia the Occupational Health, Safety and Act 1986 has been amended recently to specify bullying as

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behaviour which creates a risk to safety or health with penalties capped at AUS $20,0000 for an individual fined under the Act, or AUD $60,000 for a .

3.11. Individual contribution to workplace bullying

Despite the scope of this research focusing on the impact or influence of contextual factors on medical students’ perception, conceptualisation and experience of bullying; gaining a preliminary understanding of the individual contribution both as a target and as a person who bullies, is important in providing a balanced, clearer picture of the phenomenon of workplace bullying. Furthermore, some studies suggest that it is considered likely that individual factors such as biology, psychological attributes, personality, affect either negative or optimistic, all have significant influence over the way most people, perceive and experience bullying. While there are some investigations exploring common perceptions of medical students’ individual contribution to bullying behaviours, there are limited inquiries documenting correlation between their actual individual characteristics and abrasive or harassing behaviours, flagging a valuable area for further research studies. Initially section 3.11 will explore broader research on individual contributions to bullying behaviours in the workplace, then it will consider studies which investigate perceptions of individual contribution. There is a body of research that proposes the existence of some individual psychological or cognitive characteristics, which might influence experiences of workplace bullying. While there is a significant amounts of literature addressing the influence that individual victim psychology has over incidences of workplace bullying, most of it concentrates on what personality types and behaviours act as triggers for bullies, or what psychological factors impair the individuals ability to defend themselves against attack (Coyne, Seigner & Randall, 2000; Glasø, Matthiesen, Nielsen & Einarsen, 2007) thereby overlooking the meaning or perception of bullying that is ascribed from either the victims or perpetrators perspective. Some research suggests that perfectionists, with a of failure, which drives a willingness to do , and be the ‘perfect player’, leads to exhaustion or chronic fatigue, thereby becoming a target for exploitation by bullies (Wirtz et al., 2007). It is further suggested that perfectionism can lead to the development of fatigue related syndromes, and that such perfectionist personality types may be at risk of developing negative psychopathological symptoms after a traumatic exposure (i.e. from bullying) (Wirtz et al., 2007). There are

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also a number of studies, which suggest that those individuals who are attracted to medicine have a predisposition toward meticulous and committed personality types (Sevlever & Rice, 2010). Alternatively, it could be suggested that doctors might actually be defined as pro-social people. In an organisational context pro-social might mean someone who is always trying “to cooperate when team assignments are given, and to show and concern for others”. However, it has further been purported that such pro-social personality types are “ripe for abuse” (Namie, 2007, p. 46). One review of workplace bullying concludes that common personality characteristics of workplace bullying targets include low tolerance, self-efficacy, and high emotional volatility, coupled with fewer social supports and a history of victimisation (Magee et al., 2014). However, similarly to earlier research, the report also flagged the idea that there may not be a single victim profile for targets of workplace bulling (Glasø et al., 2007; Magee et al., 2014).

Biology of targets

Gender has also frequently been nominated as an influential factor in workplace bullying. A recent Australian study on bullying in healthcare recently noted that being a female played a significant role in increasing ones risk for being bullied by co-workers, with 32% of female doctors reporting being bullying by co-workers, as opposed to 27.9% of male doctors (Hills et al., 2011). In the Australian Medical Association’s submission to the RACS Expert Advisory Group, they highlighted the role which sex plays in the incidence of bullying amongst doctors (Owler, 2015). The AMA submission suggests that inequity within medicine, and indeed within the wider community has played a role in the increased incidence of “discrimination, bullying and sexual harassment of female employees” (Owler, 2015, p. 5). This gender differential is further borne out in the analysis that workplace-bullying researchers report in a chapter exploring the empirical findings on prevalence and risk groups of bullying in the workplace (Zapf et al., 2011). The research found that that in 53 samples, of over 5,000 ‘targets’, 62.5% were women and 37.5% were men (Zapf et al., 2011). Furthermore Zapf suggests that those women who work within a traditionally male dominated field were even more likely to be bullied than those women working in a gender-neutral environment (Zapf et al., 2011). Despite some overlap in antecedents, behaviours and outcomes, sexual harassment is considered different to bullying. Unlike bullying, sexual

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harassment is considered a type of gender-based discrimination and is clearly illegal throughout Australia, covered by anti-discrimination, , and criminal laws (Mathews & Bismark, 2015). Studies have long suggested that sexual harassment in medicine is widespread (Babaria, Abedin, Berg & Nunez–Smith, 2012; Fnais et al., 2014; RACS, 2015a, RACS, 2015b), and that sexually harassing behaviours are more likely to occur in workplaces that permit or tolerate this behaviour (Schneider, Pryor & Fitzgerald, 2011). Although considered to be two separate behaviour classifications, it stands to reason that a workplace, which allows a culture of sexual harassment, may well also overlook bullying behaviours (Butterworth, Leache & Kiely 2013; RACS, 2015b; Victorian Auditor-General, 2016). Conversely a study that explores bullying within nursing found that males (who represented less than 3% of the workforce) were nearly three times more likely to be targeted for bullying than their female colleagues (Erikson & Erikson cited by Zapf; 2011). This finding is suggestive that it is in fact a ‘majority rules’ approach to bullying based on which gender is in a minority, but that doesn’t explain why women in male dominated professions are sometimes accused of bullying other women more than they bully men, moreover, in a study of over 1000 workers, it was reported that 58% of the bullying was perpetrated by women (Namie, 2007). Although, in terms of harassment, the Royal Australasian College of Surgeons cite a study which indicates that a workplace characterised by masculinity, will often record higher incidents of harassment, perhaps leading to the idea that medical practices hallmarked by higher levels of female doctors will reduce the amount of harassment occurring (RACS, 2015c). Contrary to the majority of empirical findings on gender differences, the survey by Askew et al. of 764 Australian doctors (Askew et al., 2012) reports that they found no difference between genders when it came to targets of bullying. Using theories of victim role and passivity, some researchers have explored, and ultimately dismissed the idea that overrepresentation of female targets of bullying may be connected with female socialisation (Zapf et al., 2011). What has not been explored in the debate around sex, gender and workplace bullying, is whether women may simply perceive, conceptualise and define a bullying event differently from men. Furthermore, although there is anecdotal evidence to suggest a correlation, there are currently no known studies, which explore bullying and harassing behaviours of LGBQTI+, Lesbian Gay Bisexual Queer or Intersex, medical students, trainee and qualified doctors.

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Age and experience of workplace bullying targets

In literature on bullying in healthcare, age or experience is also flagged as a factor influencing incidents of workplace bullying. Much of the research on bullying in medicine suggests that the younger, or more junior you are, the greater the likelihood is that you will be bullied (Quine, 2002; Cheema et al., 2005; Scott, Blanshard & Child, 2008; Hills et al., 2011; Scott et al., 2015). However, few studies differentiate between lack of workplace experience and chronological age (specifically ). The question might be asked, whether people are being bullied because they are young, because they are inexperienced, or perhaps both, although it may be because those who are younger, tend to be less experienced job wise, and are therefore more vulnerable to superiors abusing their position of power. One study reports that because of a lower within the hospital, younger doctors are being targeted for bullying (Hills et al., 2011), while another study indicates that for trainee doctors there are multiple contributors to a challenging interpersonal incident (Paice et al., 2002). Paice et al.’s British study uses a questionnaire to find out that of 1435 junior doctors working in Britain, 92% of respondents described a stressful incident in their time as a pre-registration house officer (Paice et al., 2002). Notably, 29.7% of those incidents involve a difficult interpersonal relationship, and a significant percentage of that 29.7% involved senior medical staff (Paice et al., 2002). As one junior doctor said; “job 3 involved working for a particularly difficult consultant, who made his to terrify his patients, cause the registrar to cry 1-2/week, and humiliate the juniors in front of as large an audience as possible” (Paice et al., 2002, p. 59). The study by Paice and colleagues, indicates that factors such as learning to cope with being responsible for life and death matters, night duty, long hours, and missed meals, are often inextricably intertwined with behaviours of senior doctors who were unreasonably critical or demanding on trainee doctors (Paice et al., 2002). The study by Askew found no difference in the gender of those targeted by bullies, and also found no significant difference in age or job grade of victims (Askew et al., 2012). This result is similar to a survey of 311 health care workers, which found that length of service and age were not significantly associated with being bullied (Rutherford & Rissel, 2004). Some studies correlate an increase in incidents of bullying for those health-care employees who work full-time versus part- time (Quine, 1999) as well as an increase in negative consequences for those healthcare workers who identify as being bullied, and were either over 45 years of age, had an

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employment tenure of 5-9 years, or were employed part-time (Demir, Rodwell & Flower, 2013). However, Scott, et al. suggest in their summary of workplace bullying of junior doctors, that while the researchers acknowledge a “high prevalence of perceived bullying by junior doctors”, “the bullying may be a misperception by the victim” (Scott, et al., 2008, p. 1285). This statement by Scott et al. raises several questions around bullying and subjectivity, objectivity, and perception. Specifically it raises the question of whether medical students’ perception, definition or experiences of abrasive bullying behaviours will change with experience, and professional and organisational enculturation.

3.12. Individual contribution to bullying: Who bullies?

Some studies flag the possibility that there may be certain characteristics, which can be commonly found in individuals who perpetrate bullying. Although, perhaps given the reluctance of individuals to self nominate as a workplace bully, there is limited research to date on those individuals who exhibit bullying behaviours (Caponecchia & Wyatt, 2011). A number of texts, both academic and non-academic, theorise that bullying is often caused by psychological or personality traits of the perpetrator. Individual characteristics such as threatened egotism, or lack of social competency such as poor emotional control have all been mooted as possible contributors to bullying behaviours (Zapf & Einarsen, 2011). , psychopathology, lower self-esteem and emotional stability have also all been forwarded as individual characteristics of the accused bully (Magee et al., 2014). Weber suggests in a 2004 article, that doctors “have a horrible track record in our own profession of even recognizing physicians with personality disorders, much less dealing effectively with them” (Weber, 2004, pp. 8-9). The same article also reports that, whilst doctors are intelligent and mostly reasonable, they are also “deficient in interpersonal and emotional intelligence competencies” (Weber, 2004, p. 9). Moreover, there are even studies which explore the correlation between bullying and genetic pre-disposition (Harvey et al., 2009). As previously mentioned, it has been suggested that, in terms of gender and bullying, while less data exists on bullies, men are still overrepresented as ‘perpetrators’ in most of the studies, and when a study does show that women are more often bullied by other women, it was because of labour segregation (Zapf, 2011; Magee, 2014).

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A number of studies report not on personality traits of perpetrators, but focus more on leadership styles that are conducive to workplace bullying. Leadership, which is characterised as either autocratic, or liassez-faire in nature are considered by researchers to pose some of the highest risks for bullying within their workplace (Salin & Hoel, 2011; RACS, 2015a,c; Victorian Auditor-General, 2016). In terms of organisational and professional hierarchy, studies indicate that the principal source of abrasive behaviours is coming from individuals who are considered senior staff and management (Carter et al., 2013; Magee et al., 2014; Shabazz, Parry-Smith, Oates, Henderson & Mountfield, 2016). The 2015 RACS investigation found that senior surgeons and surgical consultants are reported most often as the perpetrator of bullying or harassing behaviours (RACS, 2015a, 2015b).

3.13. Perceptions of individual contribution to bullying

Given the focus of this research, it is considered relevant to explore any documented perceptions of individual contribution to workplace bullying in medicine. This section unpacks insights shared by medical students, trainee and fully qualified doctors on perceptions of individual contribution to abrasive bullying behaviours. There are only a very few relatable studies that can be referenced in this section, and they discuss perception of contribution both in terms of those being targeted, and those perpetrating the bullying behaviours. The first applicable research is a project by Gan & Snell, which aimed to explore how medical students understand ‘mistreatment’ in their learning environment (Gan & Snell, 2014), and although the study focus was solely on perception of event and definition, it highlights the importance of victim and bystander perception in understanding the phenomenon of bullying, abrasive or ‘mistreating’ workplace behaviours. What the Gan and Snell study did find in respect to individual contribution to the perception of mistreatment, was that most medical students feel that a hostile situation might be defined as ‘mistreatment’, or not, based on the targets individual personality traits or their own background (Gan & Snell, 2014). However, the idea that medical students might be more likely to see abuse in an incident or interaction, because they have personally experienced abuse has been challenged by a study that explored the relationship between medical student perceptions of mistreatment and their sensitivity to that mistreatment (Bursch et al., 2013). The study demonstrates that medical students who perceive abuse are “not simply overly

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sensitive” to abusive behaviours (Bursch et al., 2013, p.e998). Furthermore, a study by Rees notes that of the 200 medical students who participated, 153 of them perceive that the perpetrator of the mistreatment was a contributing factor in the abuse, with older age, psychological, emotional, personality characteristics, mental health and social problems, and social incompetence all recorded as factors (Rees & Monrouxe, 2011). Interestingly the same study noted that 25% of participants also apportioned contributory factors to the targets of abuse (Rees & Monrouxe, 2011). Demographic features such as gender, age and ethnicity were thought to contribute, as did perceived personality flaws such as being overly meek or extroverted, as well as ‘negative’ victim behaviours such as rebelliousness, noncompliance and poor punctuality (Rees & Monrouxe, 2011). Furthermore, individual low hierarchical status and incompetence associated with medical student status were also considered as contributory factors (Rees & Monrouxe, 2011). In a 2015 study commissioned by the Expert Advisory Group of the Royal Australasian College of Surgeons, participants nominated a lack of resilience, and a helpless or timid personality as a contributing factor to bullying and harassing behaviours (RACS, 2015b). Research participants which included a mix of 414 fellows, trainees, international medical graduates and additional medical personnel, suggested that “robust” individuals would be less likely to be bullied, and that surgery needed “to eliminate shrinking violets” from the profession (RACS, 2015b, p. 46). Moreover, the participants suggested that surgeons who bullied had inherently flawed personalities and problematic psychological profiles, proposing that they were “sociopaths”, “obsessive compulsive types”, with “abnormal behavioural norms” (RACS, 2015b, p. 46).

3.14. Perceptions of environmental influence contribution to bullying

As with section 3.13, given the focus of this research, it is considered relevant to explore any documented perceptions from medical students, trainee and fully qualified doctors on environmental contributions to workplace bullying in medicine. It is notable that there are few studies, which explore medical student or physician perceptions of environmental or contextual contributions to bullying behaviours. However, medical student participants in the study by Gan and Snell, believe that the competitive culture of medicine as well as its highly hierarchical nature both contribute to the occurrence

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and perpetuation of ‘abuse’ of medical students (Gan & Snell, 2014). This is congruent with medical students who felt that “the organizational culture of medicine”, characterised by tolerance of abusive situations, contributes not only to the ‘mistreatment’ occurring, but that the sense of powerlessness engendered by their perceived inability to do anything about it, compounds the behaviours negative impact (Rees & Monrouxe, 2011). In the RACS 2015 Confidential draft research report surgeons, both training and fully qualified, respond that the concept of power is thought to contribute to bullying and harassing behaviours (RACS, 2015b). Often the notion of power was considered in terms of individuals who have power and those who do not, with one respondent suggesting the abrasive behaviours were caused by “power centralised in an individual who is highly regarded” (RACs, 2015b, p. 35). Power abuse cemented through time, and enabled by a hierarchical system is also nominated by a number of the surgical respondents, “There is a hierarchical system which is often dictated by senior consultants behaving in a chauvinistic manner, which I believe has been handed down over time” (RACS, 2015b, p. 38). While the doctors and medical students share insights on principles such as hierarchy, culture and abuse, this researcher observes that the research respondents often nominate a relatively individualistic notion of these concepts, with a focus on individual contribution, i.e. a bullying consultant, a powerful individual doctor or administrator.

3.15. Summary of methods in current relatable workplace bullying literature

A brief summary of the methods currently found in other germane research and literature on workplace bullying reveals a dearth of quantitative methodology and methods, and some methods that are qualitative in nature. Exploring the methods employed in current workplace bullying literature illuminates those approaches used in the effective answering of research that has a focus similar to this project. The exploration of other studies research designs is another step in determining the most appropriate methods for answering the project questions and fulfilling the aim of the research. Due to the nature of the inquiries, many of the methods commonly used in current workplace bullying research have been quantitative. Much of the historic and current investigations and its associated literature focus on measuring whether bullying has taken place, and are predominantly seeking to measure or compare, or quantify the

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magnitude or impact of workplace bullying. Whilst the measures mostly rely on the participant (or subject) reporting the event, either by self-labelling or behavioural experience, the enquiry is more often than not applied in a structured questionnaire or survey format (Einarsen et al., 2011). Examples of methods frequently found in workplace bullying include, but are not limited to; the Negative Acts Questionnaire (NAQ) and the NAQ-revised (NAQ-R), which are inventories used in a number of large studies (e.g. Abe & Henly, 2010; Carter et al., 2013). The questionnaire contains 18 sectors (22 in the revised version) describing different behaviours, which, if they happen on a recurring basis, may be reported as bullying. All response categories are provided in tick box format only (Hauge et al., 2007). Cross-sectional survey design, as used in the Hills study, employ a questionnaire to determine the frequency of workplace aggression experienced by doctors in Australia (Hills et al., 2011). Other methods used in workplace bullying research and literature includes, the Workplace Scale (WIS), literature reviews and synthesis, narrative and case studies, as well as interviews. In-depth, and semi-structured questionnaires are possibly the tool used least in studies of workplace bullying, perhaps due to the time intensive nature of such interviews, or the paradigmatic nature of the investigation. However, Tracy, Lutgen-Sandvik and Alberts use semi-structured interviews in their study on and workplace bullying (Tracy et al., 2006). The American study, ‘Nightmares, demons, and slaves: Exploring the painful metaphors of workplace bullying’ aims to give voice to, and explore the stories and conceptualisations of emotional caused by workplace bullying. The methods used to gather data are qualitative in nature, and include 10 in-depth interviews and 2 focus groups, and the researchers report that the “loosely structured” interviews work well, and allow both specific areas to be addressed whilst still allowing participants the space to “narrate their experiences” (Tracy et al., 2006, p. 156). The study yields powerful results, both facilitating a way for participants to express their experiences, in use and drawing, and giving a rich insight into their experiences and interpretations. As suggested by workplace bullying expert Denise Salin, in the field of workplace bullying, surveys rarely provide sufficient data “to identify the subjective meanings and experiences of the targets” (Salin, 2003, p. 1219). I would further suggest that such methods may be of little benefit to those wanting to capture the experiences and perceptions of perpetrators either. An exploratory study aiming to understand bullying allegations from the bully’s perspective, used in-depth telephone and face-to-

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face interviews, as the researchers believed that thematic analysis based in phenomenological epistemology was required to fully “understand the everyday experiences of research participants”, and, “ in order to gain a better understanding of workplace bullying from the perspective and reality of the accused bully” (Jenkins, Zapf, Winefield & Sarris, 2011, pp. 491-492) Furthermore, the paper by Kate van Heugten, entitled ‘Resilience as an underexplored outcome of workplace bullying’ is a further example of research that engages qualitative research designs and methods to successfully answer a research question focusing on the experiences of social workers that have self-identified as targets of workplace bullying (van Heugten, 2012). Van Heugten’s research engages conversational-style interviewing of 17 participants because it enabled her “to explore the form and impacts of the phenomenon in depth” (van Heugten, 2012, p. 293). Van Heugten’s use of conversational style interview, and grounded theory analysis, allows the theme of resilience to arise inductively. Her qualitative methodology enables her to revisit her background knowledge of existing resilience theories and eventually draw significant conclusions around potential positive outcomes of workplace bullying (van Heugten, 2012). Drawing on a pragmatic paradigm, van Heugten suggests that her research both uncovers and explores problematic areas, and the paper offers solutions to potentially ameliorate the difficulty (van Heugten, 2012). Moreover, van Heugten identifies that her research instrument of interviews allow her broader exploration of a topic which, to date, has been little investigated (van Heugten, 2012). The identified gap in existing research resonated, particularly with the research gaps and limitations being noted during the initial literature review for this research, and it contributed to my own considerations of using interviews as a possible data collection instrument. While the study conducted on exploring the painful metaphors of workplace bullying, used mixed qualitative methods of focus groups, and individual in-depth interviews to investigate the impact of workplace bullying on individuals (Tracy et al., 2006), it was felt that medical student participants in this current study, may be reticent to share experience and perceptions on such a sensitive topic with other medical students present. Many studies on workplace bullying use quantitative methods to explore the phenomenon, and the contribution that these studies make by measuring what, when, who and how, are of great significance, however there are also limitations to what quantitative methods can

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show. Like the van Heugten study, the Tracy et al. study used qualitative methods to collect, explore and analyse thick, rich data from its participants.

3.16. Gaps and limitations in current knowledge of workplace bullying & medical students

The figure below (Figure 3.3) is a visual representation that highlights some of the gaps in current literature, on medical students’ experiences and perceptions of bullying amongst hospital-based doctors.

Study Charactersitics WPB Definitional Gaps Perception Gaps Gaps

•Limited studies •Absence of studies •No comparable social exploring disparity btwn exploring work led research their reported WPB multidimensional impact •Lack of independently experience & definition or influence of contexts comissioned Australian on medical student •Limited exploration of context research perception & experience •Absence of studies with perception of WPB of WPB experience juxtaposed medical students' own with operationalised •Studies on med student experience & perception definition of bullying perceptions of WPB of WPB currently focus on •No qualitative studies •Absence of studies that individual influences, consider WPB in exploring linkage btwn such as psychological, med student definition of medicine within a emotional or cognitive framework of oppression WPB & influence of appraisals of incidences. context & power abuse.

Figure 3.3. Gaps and limitations in current knowledge of workplace bullying (WPB) & medical students

3.17. Summary of identified influences of workplace bullying

Figure 3.4 is a visual representation summarising the environmental and individual factors influencing workplace bullying in medicine. These are the contributing areas, which have been explored throughout this chapter. Environmental contribution Individual contribution

Job/Task Cognitive/psychological

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Communication Biology Medical training/enculturation Age/experience Professional/organisational Perceptions of individual contribution guidelines/codes of conduct Broader economic state Community perceptions Media portrayal/involvement Parliamentary findings/legislation & Regulatory guides Perceptions of environmental contribution

Figure 3.4. Contributing factors to workplace bullying amongst doctors

3.18. Chapter summary

Chapter Three has outlined many of the contributing factors that appear in research literature on workplace bullying, specifically bullying amongst doctors. The chapter has illuminated the broader context, in which bullying, amongst hospital-based doctors, transpires. It is important to note that the wider context in which the bullying behaviours occur is not static. In Australia, with the current increased focus on workplace bullying and harassment in medicine, by the public, media, and the specific professional disciplines themselves, it is inevitable that changes will continue to occur and be reflected in, the law, organisational and professional regulations, as well as individual and community behavioural expectations. Exploring the broader, meso and macro contexts, and the multi-causal nature of bullying allows the researcher to glean potential influences both on the bullying behaviours occurring amongst hospital-based doctors, as well as any potential influences on the medical student’s perceptions, conceptualisations and experiences of those behaviours. Chapter Four will explore the role of hierarchy, power and power misuse in the facilitation of workplace bullying. It will also investigate theories of power and oppression, specifically in relation to bullying behaviours amongst hospital-based doctors. The theoretical framework of oppression, by Iris Marion Young (1990) is

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examined in the greatest depth, and will ultimately be used to consider and evaluate the research findings in the discussion chapter.

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Chapter 4. Bullying in medicine and dynamics of power and oppression

Chapter Four explores theories of power and oppression found in other relatable studies relevant to the phenomenon of workplace bullying. This chapter will form the theoretical framework used to underpin the research design, and interpret findings. The chapter also explores how bullying in medicine is sometimes defined as something other than bullying, and how medical students perceive concepts such as power and oppression in relation to bullying. This chapter provides a framework to help address research question number three, ‘how might dynamics of power and oppression contribute to our understanding of medical students’ perceptions and experiences of bullying amongst hospital-based doctors?’ Iris Marion Young’s (1990) contribution on oppression emerges as a potential best fit to help explore further, medical student perceptions and experiences of bullying amongst hospital-based doctors. Limitations of Young’s theory will also be elucidated. There is often much emphasis placed by workplace bullying experts and researchers, on power disparity between perpetrators and targets, as well as the potential role of hierarchy in creating and perpetuating abrasive behaviours. Given this focus, an exploration of power and oppression literature is considered a reasoned approach by this researcher. Many of the readings on discourses of power and theories of oppression were conducted prior to data collection so, in the interests of clarity and logical flow of this thesis, initial discussions on the subject of power and oppression should come before any of the participant findings. This literature may have had an influence on data collected, questions thought, or subject contemplations had, during the research process. Equally, the researcher is mindful that this paradigm of power and oppression might not have been how any of the participants framed their perceptions or experiences of bullying. Any data gathered must speak for itself, rather than be a reflection or interpretation of a researchers theorising, and it is for that reason that overt questions on oppression or disciplinary power were not included in the semi- guides. It can be argued, that the way the phenomenon of bullying in healthcare, and specifically amongst doctors, trainee, junior or medical students, has been historically

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framed, is not the only way to view the issue, or necessarily the most adequate choice of lens. Language used to theorise abrasive behaviours amongst doctors and medical students has often been couched as ‘mistreatment’, or in terms of concrete or specific resource restraints or deficits, as seen in the Job Demands – Control Resources (JD – CR) theory. While the conversation around mistreatment has the potential to flag broader contextual problems, and the JD-CR model does allude to aspects of oppression, they do not necessarily reflect or capture the full range of the difficulties. Furthermore, the models used and language often applied is individualistic in character. However, perhaps by using a fuller, more robust language of power and oppression when framing bullying amongst doctors, may work to more accurately reflect the magnitude and multidimensionality of the phenomenon. This framework might also help ameliorate any disconnect between the experiences reported by medical students and junior doctors, and the theories found often in writing on bullying in healthcare, as well as the definitions embedded in professional codes of conduct, organisational guidelines and regulations, and even legislation. Furthermore, viewing the phenomenon through a lens of power dynamic and oppression may raise new lines of inquiry and understandings of medical student experience and perception of bullying amongst hospital-based doctors. Included in this chapter is an outline of language choice around bullying of medical students and junior doctors, specifically the use of the term ‘mistreatment’. There is also a discussion of the impact of power dynamics on the experience, perpetuation, and reporting of bullying.

4.1. Language choice: How bullying behaviours are sometimes defined as something else

Throughout the literature on bullying in medicine, it is noted that the behaviours are often labelled as something other than bullying. In an Australian context, particularly prior to the RACS investigations of 2015, and the parliamentary Senate inquiry, incidents of bullying in medicine are often referred to as mistreatment, abuse, humiliation or disrespect. This section unpacks the various choices of label for bullying behaviours in medicine, and proposes that the label used, particularly by those in authority, may influence the behaviours themselves, as well as medical student perceptions and experience of bullying.

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It is a further assumption (refer back to Chapter One for other assumptions), of the researcher, that words used to describe and define behaviour are important. It matters because words can influence those reading, hearing, or experiencing it, particularly when the words are coming from a person or organisational representative of a position of power or authority (O’Toole, 2012). From an Interpretive standpoint, language has “built in social , so that we learn to think and see the world in certain ways” (Neuman, 2006, p. 89). There are a number of recent studies on the mistreatment of doctors in training. In 2014, Fnais et al. did a comprehensive and meta-analysis of 57 cross-sectional and 2 cohort studies, aiming to increase their understanding of mistreatment of trainee doctors (Fnais et al., 2014). The study uses the terms ‘harassment’ and ‘discrimination’ as behaviours that fall under the umbrella of mistreatment (Fnais et al., 2014). A perspective piece in the journal Academic Medicine, which explores aspects of medical culture, chooses to use the term ‘disrespectful behaviour’, to describe bullying interactions between physicians (Leape et al., 2012). Leape’s piece labels behaviours that have significant overlap with what would be considered (in policies, or occupational health and safety regulations), to be workplace bullying (Leape et al., 2012). While many of the studies exploring mistreatment of medical students are measuring prevalence and using surveys or questionnaires (Haglund, aan het Rot, Cooper & Charney, 2009; Cook, Vineet, Rasinski, Curlin & Yoon, 2014; Fnais et al., 2014), some of the studies utilise qualitative methods to answer questions with parallels to this thesis topic (Rees & Monrouxe, 2011; Gan & Snell, 2014). There were however, several main differences; including the terms they use to explore the question of medical students’ experiences and perceptions of ‘mistreatment’ or ‘abuse’, rather than bullying, also the environmental context of the ‘mistreatment’ studies predominantly focuses on the potential influence and interaction between the medical student and the learning environment, rather than a hospital environment. There are methodological differences too, with different data collection tools utilised. The difference between using the term ‘mistreatment’ and ‘bullying is an important one. While many of the studies define mistreatment in terms that are actually closely aligned with bullying (Fnais et al. 2014; Snell & Gan; 2014; Scott, Caldwell, Barnes & Barrett, 2015), it is when a label of bullying is applied to the abusive behaviour, that organisations and individuals can reflect on the depth, multiplicity and full implications of the situation, and investigate and address the issue effectively. However, the term ‘bullying’ is not

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implication free, with the word ‘bullying’ often already heavily imbued with negative connotation, sometimes coloured by images of schoolyard , but more often than not indicative of abuses which have occurred due in part to significant differentials in power (Saunders, Huynh & Goodman-Delahunty, 2007; Caponecchia & Wyatt, 2011). It is a deliberate choice of this researcher to use the word ‘bully’, ‘bullying’ and ‘bullying behaviours’ throughout this study, however it is also acknowledged that it is not always the language chosen by the participants of the study when they reflect on their experiences, nor is it the language always chosen in prior studies on abrasive bullying behaviours in medicine. With the recent focus on bullying and harassment from within many of the peak professional medical bodies and the media, within an Australian context, the terms and language used to define hostile, abrasive acts of mistreatment amongst doctors and medical students are undergoing a transition. The behaviours discussed in the participant interviews in this research are compared to, and discussed in light of definitions of bullying which are currently used extensively in both bodies of workplace bullying research, and in existing regulations and legislation aimed at addressing bullying. When workplace bullying occurs, the behaviours often have significant negative impact. The researcher considers that the term ‘mistreatment’ has the potential to minimise the detrimental impact of the abusive behaviours. Furthermore, the word bullying is often synonymous with and hierarchy which corresponds seamlessly with the experiences reported by many medical students, doctors and researchers alike (Timm, 2014; RACS, 2015b;Victorian Auditor-General, 2016). Widely available dictionaries define bullying as “to frighten or hurt someone who is smaller or weaker than you”, or to “use your influence or status to threaten or frighten someone in order to get what you want” (Macmillion Dictionary, 2017). The Oxford School Dictionary used to educate by many students in Victorian schools, define the word bully as “use strength or power to hurt or frighten a weaker person ” (Oxford School Dictionary, 2011, p. 88). The same dictionary defines mistreat as to “treat badly” (Oxford School Dictionary, 2011, p. 430). The terms used are clear, and include bullying, discrimination, and sexual harassment. Amendments of the Crimes Act (1958) refer to abusive, offensive acts and (section 21A (2) (da–dd) & 21A (2) (g) it uses language such as physical and mental harm. Nowhere in current Victorian legislation that deals with workplace abuses, is the term mistreatment used. Earlier discussions in Australian media, on abusive behaviours

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in medicine mirrored the reluctance to use the word bullying. It was not until May 2015, when there was increased public debate on the issue, that the term bullying was eventually embraced in popular media, and in some medical-academic circles. Despite the media and broader ’ increasing willingness to use the term ‘bully’ and ‘bullying’ when it comes to hostile behaviours amongst doctors, a recent special edition of the Medical Journal of Australia uses the phrase ‘bad behaviour’ to describe abusive conduct, and features an article on teaching by humiliation and mistreatment of medical students (Scott et al., 2015). This raises questions around, what influence might language choices have on medical student’s perceptions of bullying in medicine? The study by Rees exploring medical student narratives, identify types of student responses and contributing factors to perceived abuse (Rees & Monrouxe, 2011), however this study is explicit in why it chooses to use the term abuse rather than bullying, citing the “fleeting relationships” that medical students typically have with other healthcare professionals (Rees & Monrouxe, 2011). The research by Gan and Snell suggests that the way in which medical students perceive a negative situation is complex, and that there are multiple, interacting environmental and individual influences on that perception (Gan & Snell, 2014), and while there are possible limitations in applying some of the Canadian ‘mistreatment studies’ to an Australian cultural context, many of the questions discussed and the conclusions reached, are vitally important to this research (Gan & Snell, 2014). Furthermore, the Canadian study also raises the question, of whether ‘mistreatment’ could mean “more than we think” (Gan & Snell, 2014, p. 608), pointedly asking readers “are there other types of perceived mistreatment that have not been clearly studied…” (Gan & Snell, 2014, p. 609). The study by Gan and Snell provides a solid foundation for this research, which explores medical students’ perceptions, conceptualisations and experiences of bullying amongst hospital-based doctors (Gan & Snell, 2014).

4.2. Medical students perceptions on power, oppression, hierarchy and bullying

A core focus of this research includes the exploration of medical students perceptions of bullying amongst hospital-based doctors and how dynamics of power and oppression may contribute to our understanding. Therefore it is salient to explore any research that documents medical students’ own perceptions of power, oppression and hierarchy. As

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outlined in the preceding chapters, it is not uncommon for medical students to be exposed to bullying or mistreatment on clinical placements, and often at the hands of senior doctors or their direct medical mentors or supervisors (Bourgeois et al., 1993; Cook et al., 2014; Oser et al., 2014). Likewise, it is also indicated that medical students are more vulnerable to mistreatment on campus, from staff in the Faculty of Medicine, when compared to students from other Faculties (Rautio, Sunnari, Nuutinen & Litala, 2005). There are two studies in particular that touch on medical student perceptions of power dynamics and its role in mistreatment or abuse. Participants in the Gan and Snell study report that they feel that ‘power dynamics’ contribute to the way they perceive and react to abrasive situations (Gan & Snell, 2014). The participants acknowledge that they are low on the hierarchical scale, and perceive that that power status limits their range of responses to mistreatment, thus further potentially increasing their sense of frustration and vulnerability (Gan & Snell, 2014). Additionally, participants in the Rees and Monrouxe study exploring medical students narratives of abuse, report that their “lowly status”, being “the lowest of the low” contributes to being at risk of abuse in the workplace, as well as being unable to challenge the abuse (Rees & Monrouxe, 2011, p. 1377). When it comes to medical students’ perception on organisational contribution to abuse, participants in the Rees and Monrouxe study suggest that they did nothing because of the organisational hierarchy, describing “their own sense of inferiority and disempowerment”, and describes a professional and organisational social etiquette which prohibits them from appearing to undermine a consultants professional authority (Rees & Monrouxe, 2011, p. 1378).

4.3. The connections between power, organisational hierarchy, bullying and development of a workplace culture

This section includes a broader contextual discussion of the influence of power dynamics on bullying behaviours in hospitals and the medical profession. Closely connected with other influencing organisational factors, is the concept of hierarchy, power and workplace culture. Research indicates that rigid hierarchy, whether professional, organisational or both, can impact on prevalence and perpetuation of bullying behaviours (Salin, 2003; Einarsen, Hoel, Zapf & Cooper, 2011; St-Pierre, 2012). There are questions around how within an organisation, both structural hierarchy, (which is often typified by a traditional organisational chart), and

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perceived hierarchy, (which is an individual’s subjective perception of their position within the organisational hierarchy), might impact experiences and perceptions of workplace bullying. Hierarchy is described in terms of both structure and process, so that the structure of an organisation will inevitably influence all of the processes possible within (St-Pierre, 2012). The Hills, Joyce and Humphreys’ study suggests that working in a hospital actually increases a doctor’s chance of being bullied at work (Hills et al., 2011). This study uses data taken from the pilot phase of the Medicine in Australia, Balancing Employment and Life (MABEL) study. MABEL is a cross- sectional survey of the Australian clinical medical workforce in 2010, and the aim of Hills and colleagues’ paper is to determine prevalence or extent of aggression directed towards doctors working in Australian healthcare settings, as well as measure the present strategies in the associated workplace. Other research also suggests that hierarchy can establish which direction bullying occurs, from top to bottom (Caponecchia & Wyatt, 2011), or horizontally, which is sometimes considered a hallmark of bullying the nursing profession (Rodwell & Demir, 2012b). Studies also indicate that bullying occurs top down, however, one thesis and its associated literature has shown that upwards bullying does occur, and that out of 128 managers, 22% of respondents self-identified as having being bullied from an individual who is ranked below themselves in the formal organisational hierarchy (Branch, 2007). Moreover, while power stemming from hierarchical authority is shown to foster bullying and abrasive behaviours, a power imbalance (which is deemed necessary for bullying to occur) can happen between any workers irrespective of their organisational position (Caponecchia & Wyatt, 2011). With strict hierarchy, organisations such as hospitals, can often foster high levels of workplace bullying, with doctors potentially engaging in hostile interpersonal conflicts in multiple management directions, as opposed to nurses who more often than not engage in horizontal bullying because “they can’t take it upwards” (Rendle cited in Sweet, 2005, p. 16). This concept of directional bullying can be linked to an individual’s perception of their hierarchy within the organisation. St-Pierre reported in her study, that there are some health professionals who feel powerless, and “at the bottom of the totem pole”, with so called ‘superior’ professionals dismissing their contribution, solely because of their lower status (St-Pierre, 2012, p. 136). It is possible to extrapolate St-Pierre’s idea that the perceived ‘lower status’ of an individual can not only apply to different health professions, but also to different ranks within a profession. As one participant in St-

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Pierre’s study points out, “academic arrogance, where people with higher education or a higher status because of their education, did not perceive that lower status colleagues could contribute to the team” (St-Pierre, 2012, p. 136). The idea of ‘academic arrogance’ based on levels of education, matches seamlessly with what medical students report around the ritual of academic humiliation by senior medical staff (Kassebaum & Cutler, 1998; Paice & Smith, 2009; Rees & Monrouxe, 2011; Gan & Snell, 2014; Medew, 2015a; RACS, 2015b). There are questions to be asked around how the structure and processes of a hospital, culture and perhaps even medicine as a profession, allow, contribute, foster or perpetuate such a hostile, or bullying environment. As mentioned in earlier chapters, there are a multitude of possible contributing factors, a lack of clear goals, role conflict, or ambiguity often feature in workplaces rife with bullying (Salin & Hoel, 2011). Though prior studies and anecdotal evidence suggests bullying is ubiquitous amongst medical students, doctors, and trainee doctors (Quine, 2002; Rutherford & Rissel, 2004; Scott et al., 2008; Stebbing et al., 2004; Hills et al., 2011; Askew et al., 2012; Carter et al., 2013; Timm, 2014; RACS, 2015a; RACS, 2015b; Shabazz, Parry-Smith, Oates, Henderson & Mountfield, 2016; Commonwealth of Australia, 2016), it is not currently clear how much role conflict or ambiguity is a contributing factor in doctors or medical students being bullied. However, it does raise the question; does the necessity for hospital-based doctors to work in collaboration across units, hierarchies, specialities and even campuses contribute to the incidence of bullying? In her 2012 study, St-Pierre uses Foucault’s theories of disciplinary power, which are inclusive of hierarchical observation, normalising judgment, and relationship between power and knowledge, to explore the influence that power could have in the instigation and perpetuation of intra and inter professional aggression (St-Pierre, 2012). The outcome of St-Pierre’s study supports the supposition that through the use of power, an abrasive, hostile culture can be developed, a culture which could initiate and foster behaviours consistent with workplace bullying (St-Pierre, 2012). It appears possible that power, the disparity in power between individual targets and bullies, and the abuse of power, could have an enormous impact, not just on initially instigating incidences of workplace bullying, but also in the targets, bullies, and bystanders’ experience, conceptualisation, and definition of workplace bullying. One enormously powerful and real by-product of organisational hierarchy and power abuse is fear of retribution, or retaliation for reporting workplace abuse.

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Research on work retaliation victimisation suggests a correlation between low power statuses of the victim of abusive behaviours, with an increased chance of retaliation (Cortina & Magley, 2003). Conversely, not reporting mistreatment in the workplace can also have negative psychological and emotional outcomes on those individual targets that do not voice their dissatisfaction (Cortina & Magley, 2003). In a 2011 Medical Journal of Australia report, containing data from the Australian Medical Association (AMA) Specialist Trainees Survey, medical specialist trainees reported that they felt unable to “raise concerns without fear or recrimination” and believed that “responsiveness to cases of bullying and harassment” was problematic (Mitchell et al., 2011, p. 382). Moreover, a recent editorial in the Medical Journal of Australia suggested that when it comes to discrimination, bullying and sexual harassment, “most incidents are not reported. Reasons include lack of confidence in complaint processes, fear of adverse consequences, reluctance to be viewed as a victim and cultural minimisation of the problem” (Flynn, 2015, p. 163). Further to this, the recent Australian parliamentary investigation into bullying and harassment in medicine also found that those junior doctors or medical students who voiced their concern about bullying behaviours were both subjected to, and fearful of, forms of work retaliation victimisation (WRV) and social retaliation victimisation (SRV) (Cortina & Magley, 2003; Commonwealth of Australia, 2016). Moreover, in Cortina’s study on abrasive behaviours and workplace retaliation, both formal and informal organisational and professional power emerged as a central theme in the incidence of both WRV and SRV, with lower victim occupational status (compared to perpetrator status) being a strong correlate for increased chance of both WR and SR retaliation (Cortina & Magley, 2003). The study hypothesises that their results demonstrate that organisations use fear of retaliation to control employees from deviating against workplace cultural norms, and that organisational climates where leaders either model, mentor or tolerate hostile behaviours will ultimately perpetuate and foster such conduct (Cortina & Magley, 2003). These concepts of retribution may be useful in understanding the reluctance, as identified in some studies, for medical students and junior doctors to report bullying behaviours (Dyrbye & Shanafelt, 2011; Rees & Monrouxe, 2011; AMSA, 2015; RACS, 2015b). Arguably, how a medical student or doctor defines, conceptualises and experiences workplace bullying will be influenced by multiple contextual factors. Power dynamics within a doctor’s professional life, and organisational dimensions have

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the potential to influence how a medical student, trainee doctor or fully qualified doctor conceptualises and defines workplace bullying. Can a particular workplace culture be heavily shaped by the exchanges of power within, and in turn how might the culture of a workplace influence how a medical student experiences, defines and conceptualises bullying? Some research also indicates that those considered powerful, are individuals and groups at the top of the professional or organisational hierarchical ladder, individuals who are able to implement or influence decisions, outcomes or policy, and those individuals who have been in a position within the organisation for a great length of time, thereby accumulating and disseminating practice wisdom, and knowledge of the dominant cultural discourse (Keashly & Jagatic, 2011; St-Pierre, 2012; Rodwell, Demir & Flower, 2013). Research demonstrates that organisations with an emphasis on formality and goal-orientation, have an increased likelihood of bullying (Salin & Hoel, 2011; Magee et al., 2014). While other workplace researchers also argue that a highly hierarchical workplace increases the potential for workplace bullying to occur (Rutherford & Rissell, 2004; Hauge, Skogstad & Einarsen, 2007; LaVan & Martin, 2008; Einarsen et al., 2011). Any workplace culture that fosters, and tolerates bullying, has the potential to significantly influence not just the experiences of medical students, trainee and fully qualified doctors, but also how they may initially define, perceive and conceptualise a workplace-bullying event. Furthermore, researchers report that a workplace environment that prizes has a high degree of pressure and competition amongst workers, while allowing them little sense of control, is ripe for workplace bullying to occur (Tuckey, Dollard, Hosking & Winefield, 2009; Einarsen et al., 2011; Rodwell et al., 2013). There are a number of other studies, which have generated theories aiming to explain the cause of bullying, by exploring and applying the influence of power dynamics on abrasive workplace behaviours (Cortina & Magley, 2003; Bowling & Beehr, 2006; Hauge et al., 2007; Dhar, 2012; St-Pierre, 2012). Bowling and Beehr suggest that, in terms of power, anything from greater physical size, more supporters on one side, through to a more powerful formal position within the organisation can prove an antecedent to harassment and bullying (Bowling & Beehr, 2006). However, it is also interesting to note that in one study, perceptions on power or status as a contributing factor to bullying, varies significantly between targets of bullying, bystanders and

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managers, with the bullied participants attributing 63.6% of bullying to status or position, compared to only 44.4% of managers (Quigg, 2011). Social work academic Bob Mullaly argues that power abuse, specifically oppression, is embedded in three interactive levels; personal, cultural and structural, and that oppression can be found within multiple institutional and professional practices (Mullaly, 2010). This is congruent with other researchers and theorists who also suggest that many of the core hospital and medical professional structures, standards, traditions, norms, values, procedures and processes can be oppressive in nature (Grbich, 1999; Foucault, 1977; Petersen & Bunton, 1998; Kushner & Thomaasma, (2006). Arguably, given the decidedly restrictive, or oppressive nature of some of the hospital and professional structures, processes and dynamics, it is reasonable to extrapolate that these same characteristics may also influence how medical students come to perceive and experience incidents of bullying.

Workplace bullying and oppression

Initially this section explores briefly the Job Demand-Control-Support model, followed by a more detailed exploration of Young’s Five Faces theory. Originally the Job Demand-Control-Support (JD-C-S) model was used to explore and explain work stress (van Der Doef & Maes, 1999). However, it has since been used in a number of studies that explore the impact of resources on bullying prevenance, explaining higher levels of bullying or abrasive interactions in workplaces (Baillien, Rodríguez-Muñoz, de Witte, Notelaers & Moreno-Jiménez, 2011; Butterworth, Leache & Kiely, 2013). One Australian study found increased levels of bullying in workplaces where job demands increase as support, control and resources decrease (Tuckey et al., 2009). The same study also notes that these incidences are occurring in high stress situations and that most of the perpetrators are organisationally ranked higher than their targets, or ‘victims’ (Tuckey et al., 2009). This theory of workplace oppression – of high demands and low resources such as control, autonomy and social support from supervisors and co-workers – is used in a number of Australian studies exploring bullying amongst nurses (Rodwell & Demir, 2012a; Rodwell, Demir & Flower 2013). While the JD-C-S model has proven popular in explaining bullying behaviours as an outcome of ‘social strain’, and it has clear strengths in establishing a relationship between workload,

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autonomy and available supports, it is not designed for, nor capable of, capturing the full depth, breadth and interconnectedness of oppression and bullying in the workplace. The concept of oppression, which this study will use as its theoretical underpinning for the discussion of research findings, is the political theorist Iris Young’s Five Faces of Oppression. To date, this theory has not been applied to the phenomenon of workplace bullying. The Five Faces theory includes the notions of exploitation, marginalisation, powerlessness, cultural domination and violence (Young, 1990). Young believes that oppression is structural, and that the cause of oppression is “embedded in unquestioned norms, habits, and symbols, in the assumptions underlying institutional rules and the collective consequences of following those rules” (Young, 1990, p. 41), and at the heart of these everyday oppressive practices is the use, abuse and exercise of power. Many of the practices and processes found within hospitals are inherently linked to power. Examples of such structures and processes found operating in hospitals, educational institutes and professional bodies might include, hierarchical observational and monitoring. This observational monitoring can be evident in ward rounds, reporting meetings/sessions, handovers, report writing, key performance indicators, measures and even the architecture of hospitals. Unrealistic KPI’s in respect to number of patients seen and the associated time frame is an administrative pressure which can lead to exploitation, particularly of junior doctors keen to fit in to a particular culture. Furthermore, marginalisation may occur when medical students and junior doctors are excluded from conversations and learning experiences facilitated by senior doctors. Applying the Five Faces of Oppression paradigm, if medical students and junior doctors are given only limited access to resources, limited control over aspects of their work, and are exposed to disrespect because of their status of medical student or trainee doctor, it could be considered to represent a state of powerlessness (Mullaly, 2010; Young, 1990). By extension it is reasonable to suggest that powerlessness may also impact a medical students’ capacity to either define, conceptualise, stop or report on abrasive behaviours that they may have either experienced or witnessed. Furthermore, the notion of cultural dominance may explain how a dominant groups experiences, values and beliefs becomes the universal norm. The dominant group can widely and aggressively forecast their particular perspective as ‘the norm’, a of sorts, with any differences in groups labelled as deficient, deviant, lacking in some way. The vulnerable, ‘lesser’ group then become marked as “Other” (Young,

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1990, p. 59). Violence is the final face of oppression according to Young’s paradigm (Young, 1990). Young outlines the concept of violence in terms of random, or unprovoked attacks, which have little motive other than “to damage, humiliate, or destroy the person”, but which are also surrounded by an environmental context, which makes the particular, acts not just possible but “even acceptable” (Young, 1990, p. 61). The violence can be not only physical in nature, but also comprise of behaviours such as “harassment, ridicule, and intimidation, all of which serve the purpose of stigmatising group members” (Mullaly, 2010). Using Young’s definition of violence, workplace bullying amongst doctors, and in particular behaviours targeting junior doctors and medical students can be considered as violent in nature. The violence, which medical students might be subject to, could be considered structural in nature, given that it is tolerated and found unsurprising by the dominant cultural group (senior doctors) (Mullaly, 2010). According to Mullaly, horizontal violence is hallmarked by acts of violence that are carried out by members of the subordinate group, on other members of that same group (Mullaly, 2010). Additionally, the psychological process of inferiorisation entails the acceptance of inferior status by a member of the oppressed group, as well as a belief that all other members of the same group are ‘lesser than’ the dominant group (Mullaly, 2010). Furthermore, through the process of internalised oppression, Mullaly suggests that members of the same ‘lesser’ group can become divided through mistrust, divisiveness and a belief in their own inferiority, which in turn can lead to acts of horizontal violence (Mullaly, 2010). Internalised oppression and domination is a factor which helps account for individual reactions to oppression, and it can be defined as “a belief that one’s self and one’s are inferior…” and “also encompasses behaviours that are self-harming and contribute to one’s own oppression” (Mullaly, 2010, p.162). Internalised oppression is a psychological mechanism that assists in maintaining the status quo of control and oppression, by ensuring the repressed group come to believe in their own innate inferiority and their powerlessness to change anything (Mullaly, 2010). Using Iris Young’s key components, or ‘Five Faces’ of Oppression (Young, 1990), a visual representation of a theoretical relationship between oppression, bullying and medical student perception can be found in Figure 4.1.

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Figure 4.1. Relationships between oppression, bullying and medical student perception

There are limitations to what Young’s Five Faces of Oppression can illuminate within the context of this research. While Young’s five categories encompass oppression in terms of injustice and inequity, in issues of distribution as well as social structures, practices, processes and interactions, the categories do not cover the influence of bio- psycho-social aspects of individuals, nor the psychology of oppression. Psychological processes of inferiority and internalised oppression are central to better understanding medical students’ perceptions and experiences of bullying amongst hospital-based doctors.

4.4 Chapter summary

Chapter Four has outlined a number of power dynamics, which have been applied to explaining, and better understanding the phenomena of bullying behaviours in medicine. Furthermore, this chapter has flagged some concepts of power and oppression, specifically Iris Young’s Five Faces of Oppression theory, which are not

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presently connected with the current conversation around bullying in medicine, but could enhance our understandings on the topic. The chapter content also raises the possibility that there are valid, alternative ways to frame the current discourse on bullying in medicine. The next chapter will outline the research design, the methodology and methods, employed to help answer the research question and aims.

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Chapter 5. Research design

This chapter explains how the research design allows for gaps that were identified in preceding chapters to be redressed. Chapter Five also explores the methodology used for this study; and examines why qualitative methods were engaged in research design and analysis, and why semi structured interviews of medical students were considered the best method to apply to the research questions being asked. Moreover, this chapter covers in descriptive detail, the methods used to investigate the project’s research questions. Finally, the rigour of both the methodology and methods employed are explored, as are their limitations and strengths.

5.1. Methodology

Research design

The ontological foundation of this study sits with the recognition of the multiplicity of subjective experiences, perceptions, truth and for individuals; that there is no one single objective reality to be captured by this research (Hennick, Hutter & Bailey, 2011). As the primary researcher, I considered that the reality of the participant was defined by their own subjective interpretations of the world around them. Their reality, perceptions and understanding of what was happening around them, would be influenced in part by the contexts in which they the individual were situated (Liamputtong, 2010). The study’s aim was to gain an enhanced understanding of medical students’ perceptions, and experiences of workplace bullying amongst hospital- based doctors. These research aims and questions lent themselves to the use of a constructivist framework, where the subjectivity of medical student experience, and the acknowledgement of how contexts, environment, processes and situations sit within a broader sphere of influence, can be fully elucidated (Liamputtong, 2010). In contrast, a positivist paradigm assumes that there is an objective reality, one that is independent from our experiences (Liamputtong, 2010). A positivist framework may be an appropriate research model for measuring prevalence of workplace bullying, or generating a model of prediction (Nielsen, Notelaers & Eirarsen, 2011). However, the research questions and aim of this project required a social science paradigm that

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allowed for participants to share their conceptualisations and lived experiences in a context where their knowledge and perspective was encouraged to emerge on their terms, in their language, and on their time. The three research questions that were central to this research design included: 1. How do some medical students’ perceive bullying amongst hospital-based doctors? 2. What are medical students’ experiences of bullying amongst hospital-based doctors? 3. How might power and oppression dynamics contribute to our understanding of medical students’ perceptions and experiences of bullying amongst hospital- based doctors?

Using an interpretive model allowed the researcher to discover or gain Verstehen, a nuanced understanding of the lived experience of the participant, in the environmental and chronological context particular to them (Neuman, 2006; Hennick et al., 2011). Furthermore utilising constructivist methodology, allowed for recognition that a researcher would be viewing the research topic, questions, participants and processes through their own lens, with the researcher’s own values, beliefs and sentiments impacting on all aspects of the research project (Liamputtong, 2010). The constructivist researcher holds the position of relativism, not assuming that one value is superior to another, but simultaneously recognising that as an investigator they influence the inquiry with values of their own (Lincoln & Guba, 1985; Braun & Clarke, 2006). Research would be influenced by choice of problem and theoretical paradigm applied, as well as the theory or theories applied to data collection and analysis (Liamputtong, 2010). As outlined in Chapter Four, the theoretical underpinnings of the research reside in concepts of power, and power abuse. Whilst Foucault’s notions of disciplinary power (specifically hierarchical observation normalising judgment, and the relationship between power and knowledge) were explored in the context of another study (St- Pierre, 2012), it was ultimately decided that Young’s Five Faces of Oppression was the best fit for the research focus. In respect to power abuse, Young explores how exploitation, marginalisation, powerlessness, cultural domination and violence are all central to oppression (Young, 1990). Since constructivist studies acknowledge that no person or interaction is value free, there was a need for researcher reflexivity, both personal and interpersonal. Such reflexivity should highlight how the researchers own

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and background might have impacted on the research process and data generated (Hennick et al., 2011). Furthermore an understanding of biases and background would help safeguard against unforseen research and promote a more rigorous research process (Lincoln & Guba, 1985). As mentioned in Chapter One, although there was no timeline overlap with participants, the researcher had previously worked in hospitals that a number of the participants had done placements in, and she had also taught in the medical school where a number of the students attended. The fact that both the social work practice and teaching had been done a number of years earlier, would position the researcher as both an and an outsider within the study. The researcher has to consider at this , whether her insider/outsider status had revelatory potential, or whether it rendered her blind to seeing the issues objectively (Pelias, 2011). The researcher reflected that while working at the hospital, her capacity to see the full scope of the issue would have been undoubtedly limited by her enculturation into the hospitals’ dominant medical culture. However, it was, perhaps, only with the benefit of being on the fringes of that medical culture that the researcher could be considered by medical students as having enough insider status for them to fully engage and share their insights with. However, conversely, the outsider status possibly provided enough distance from the medical profession that there was little perceived chance of the researcher, or her study, adversely impacting their career. It was considered that for this study, the epistemological paradigm that best allowed the researcher to gain answers to their research questions was qualitative in nature. Furthermore, using a constructivist framework and methods was important in the facilitation of a sounder understanding of medical students’ perceptions and experiences, and allowed the researcher to understand better any influences and contexts (Hennick et al., 2011). Although the ontological influence within this study was generally constructivist in flavour, there was however, also a role for . There was an objective reality of what constituted bullying in the workplace, and that objective definition could be found enshrined in laws, in workplace policies and professional codes and regulations. Within this research, that objective reality was captured in the hypothetical case scenario, a scenario found in the interview (data collection method), where the behaviours and situation outlined contained a consolidation of actual criteria used to currently define bullying in Victoria. The sources used to inform the hypothetical include the Crimes Amendment (Bullying) Bill 2011, Occupational Health and Safety Act 2004, WorkSafe Victoria regulations, Royal

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Australasian College of Surgeons (RACS) Guidelines to bullying and harassment, as well as the Australian Medical Association (AMA) position statement of Workplace bullying and harassment (AMA, 2015). There is an assumption in the paradigm of pragmatism that problems uncovered by the research can be ameliorated by available solutions, and that with continual evaluation, these solutions can be applied (Liamputtong, 2010). The researcher subscribed to this assumption, and argued, that, just like the laws, policies, regulations and professional codes of conduct would suggest, there was a better, healthier way to interact with colleagues than bullying, humiliation or harassment. Pragmatism contends that there are natural and physical realities, as well as psychological and social realities, which are inclusive of subjective, experience and thought (Grbich, 1999; Liamputtong, 2010). This could be considered a researcher assumption, which should be declared, that there were indeed alternative solutions to any deficits in organisations, systems, structures, or processes, uncovered by this research, and that this belief may influence the direction the research has taken, the questions asked, and any implications put forward for further research. However, while pragmatists considered that knowledge was constructed and based on the reality of the world in which we live, constructivism, suggested that reality was always socially constructed and defined solely by individual interpretation (Liamputtong, 2010). The researcher ascribed to the constructivist viewpoint that the beliefs, perceptions and interactions of the medical students create their reality; and that their language choice, actions and the actions of those around them are also socially constructed (Neuman, 2006). There was a real tension that existed in recognising the objective realities of bullying behaviours and acknowledging the subjectively constructed truths of the individual participants’ experiences. This was a challenge, which, may be familiar to many researchers who are unpacking the phenomenon of workplace bullying, however the need to continually grapple with this tension should still be made explicit.

Functions of the research design

The project design needed to allow for this study to address the gaps in current related knowledge, as well as assist in answering the research questions and aim. In order to do this, the research design had two key tasks. The first was to facilitate capturing the realities, perceptions and experience of current Victorian medical students, in respect to

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workplace bullying amongst medical doctors. The second task was to produce meaningful, and ‘trustworthy’ data and results. It has already been established that the most suitable paradigm for this particular research was constructivist in nature. It therefore followed, that in order for the most information-rich insights to be captured, the research design had to employ suitable constructivist methods of sampling and data collection. The data and results could only be meaningful if the research process has rigour. Qualitatively, research ‘trustworthiness’ is found in study credibility, transferability, dependability and confirmability (Liamputtong, 2010). The researcher purposively recruited participants, and has thoroughly documented in the methods section of this chapter, the steps taken in data collection and analysis to ensure findings are an accurate and credible representation of what the medical students shared. While there are naturally some limitations to the transferability of the research findings, most aspects of the research process had been designed to optimise the results generalisability, from inclusion in the literature review of other professional contexts, to decisions on where to conduct participant interviews. Discussion of applicability to other contexts is unpacked further in Chapter Nine. Dependability was achieved through keeping clear, traceable, logical notes, memos, and a research journal through the data collection and analysis phases (Appendix 1.). In order to achieve confirmability, the researcher also engaged in reflexive research practice. Reflexive research practice included questioning and exploring on a regular basis my own existing biases, background, and reactions to the participants, the data and the process itself. Furthermore, a regular research journal was kept, where questions, emotions, motivations and reactions were noted. The researcher also completed reflexivity exercises such as the one found in Robson’s text on real world research (Robson, 2005). The exercise utilised reflexivity to help “identify areas of potential researcher bias” (Robson, 2005, p. 173). Robson asked that the researcher address 10 key areas relating to their own personal feelings, experiences, biases, assumptions, personal values, and applying it to different aspects of the research process (Robson, 2005). Some of the suggestions Robson gave to the researcher include, “Recognise feelings that indicate a lack of neutrality. These include avoiding situations in which you might experience negative feelings, seeking out situations in which you will experience positive feelings” (Robson, 2005, p. 173). Robson also asked investigators to “clarify your personal value systems and acknowledge areas in which you are subjective”, as

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well as reflect on your analysis and ask yourself “are you quoting more from one respondent than another? If you are, ask yourself why” (Robson, 2005, p. 173). Production of meaningful and trustworthy data and results could only be established if the study had a high level of theoretical and conceptual synergy (Grbich, 1999; Darlington & Scott, 2002; Hennick et al., 2011; Liamputtong, 2010; Lincoln, Lynham & Guba, 2011). Rigour could be achieved if the theory and concepts were thoughtfully selected, allowing consistency in the research strategy and research aims (Liamputtong Rice & Ezzy, 2001). A rigorous study should have congruence between the aim(s), question(s) and methods utilised (Liamputtong Rice & Ezzy, 2001) in order to gather and analysis data. An example of such congruence in this particular study might be found in the decision to use a constructionist paradigm to frame the research aims and questions, using the tool of semi-structured in-depth interviews to gather data, and thematic analysis to identify results. As Braun and Clarke suggested, “it is essential that the theoretical framework and methods match what the researcher wants to know” (Braun & Clarke, 2006, p. 80). Furthermore, such rigour could only be achieved once each research design decision was acknowledged by the researchers as a deliberate choice, and made transparent in each step of the research process (Braun & Clarke, 2006). As previously mentioned, constructivist research asserted that both the participants and the researchers socially construct knowledge (Neuman, 2006). Acknowledging and for the constructivist notion that inquiry is inherently value laden and influenced from a number of competing spheres, was an important step in the process to producing rigorous research and authentic results. Included in Chapter Three was an outline of and methods used in current comparative or relatable workplace bullying literature, and it was found that while most studies relied on quantitative methods to answer their questions on prevalence or measurement studies, it was research design that was qualitative in nature which would best fulfil the aim and answer the 3 core questions of this project. The aim of this project was essentially to explore individual perceptions of medical students, and by using qualitative methods it allowed the researcher to “capture lived experiences of the social world and the meanings people give these experiences from their own perspective” (Corti & Thompson, 2004, p. 326), in a manner that a quantitative method may not.

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Ethical considerations

The researcher was cognisant at all times during the research process, of observing the four key ethical principles of respect for autonomy, beneficence, non-maleficence and justice (Beauchamp & Childress, 2010). Similarly, commentary found in a text edited by Denzin and Lincoln, broke the code of ethics down into four guiding principles for inductive science, those principles were; informed consent, , privacy and confidentiality, and accuracy (Christians, 2011). By observing these four values, it may also mean that the additional four ethical principles of autonomy, beneficence, non- maleficence and justice were also likely to be privileged during the research process. In this section, the broader ethical principles will be flagged, with details or particular examples of ethical outlined in the methods section of this chapter.

Informed consent

There is an underlying assumption that the medical students who are purposively recruited to participate in this study do not have impaired capacity to make choices. In fact much research indicates that successfully admitted medical students have exceptional cognitive skills and content knowledge, with solid communication, psychomotor abilities and personal aptitudes (Powis, 1994; Kamal, 2005; Monroe, Quinn, Samuelson, Dunleavy & Dowd, 2013). Moreover, the researcher subscribes to the interpretive notion that “ordinary people use common sense to guide them in daily living” (Neuman, 2005, p. 91), and that the medical students who are interested in participating have full capacity to make informed choices in regard to their participation or not. Additionally participants do not belong to a vulnerable population, they are not children, persons with cognitive impairments, prisoners, or otherwise ‘captive’ groups (Robson, 2005). Constructivist inquiries will always emphasis “voluntary individual free choice” (Neuman, 2006), and the concept of informed consent is congruent with the projects commitment to individual participant autonomy. Furthermore, autonomy to choose whether or not to be part of the study helps safeguard the equality of power between the researcher and the participant (Ramcharan, 2010). It was, however, also the responsibility of the researcher to provide all available information to interested medical students so that they can make a fully informed choice on whether they would participate or not. For informed consent to be possible, medical students needed both to

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participate on a voluntary basis, and agree to participate based on unambiguous and complete information (Christians, 2011, p. 65). Particulars of medical student recruitment, in relation to privileging the concept of informed consent, are addressed in the methods section of this chapter. The researcher also uses reflexivity exercises to remain cognisant and self- critical regarding issues of power and hierarchy in the research process. However, the researcher remained aware that despite all the research design measures taken to safeguard the participants’ power and authority parity, participants “put themselves very much in your hands by exposing themselves in a one-sided relationship. When you come to depart you take their words away, to be objectified in an interview transcript. In the end you are very powerful…” (Ribbens, 1989, p. 587 cited in Darlington & Scott, 2002, p. 51).

Deception

Following on from the discussion of autonomy and informed consent, is the concept that the research should be clear from deception. Researchers must design investigations that are “free from active deception” (Christians, 2011, p. 65). There is no active deception in the design and execution of this research. At all times the researcher aims to make the research process as transparent as possible for the participants. Furthermore if research process and procedures are administered fairly, and in a non-exploitative manner, then the ethical principle of justice can also be honoured, (Hennick et al., 2011). An example of how this research honours the principle of justice is by not deceiving participants simply in order to gain research data. Conversely for the researcher, while measures are put in place to reduce the risk of identity deception, the researcher did not ask to sight the participants’ student identity cards.

Protection of privacy and confidentiality

All codes of ethics require research projects to have safeguards and measures in place to protect participant identity and location detail, with all personal data “secured or concealed and made public only behind a shield of anonymity” (Christians, 2011). Whilst every effort was made to safeguard the participants’ privacy and confidentiality, it was acknowledged that watertight confidentiality was almost impossible to guarantee research participants (Christians, 2011). However, reasonable confidentiality measures

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should protect the “true identity of the participants to protect them from any negative consequences” (Ramcharan, 2011, p. 30), and thus functioning to fulfil the ethical principle of non-maleficence. The protection of participants’ privacy and confidentiality was of paramount importance when designing the research. The subject matter was considered as potentially sensitive, by both the researcher and by the School of Health Sciences Human Ethics Advisory Group (HEAG). Furthermore, the researcher noted the participants’ fear of professional reprisal for their involvement in the project was not insignificant. As previously noted, this concern was not out of line with other studies and literature regarding the fear of retaliation for medical students and junior doctors speaking out about bullying in medicine (Fnais et al., 2014; RACS, 2015b; AMSA, 2016). Examples of how this project protected the privacy and confidentiality of the participants are detailed in the methods section of this chapter.

Accuracy

Maintaining data accuracy was vital to research rigour (Liamputtong Rice & Ezzy, 2001; Robson, 2005). “Fabrications, fraudulent materials, omissions and contrivances are both non-scientific and unethical” (Christians, 2011, p. 66). The researcher used the checklist of ‘description, interpretation and theory’ to safeguard that research accuracy or legitimacy was maintained (Robson, 2005, p. 171). To ensure authenticity and accuracy in the research process, interviews were audiotaped, transcription of the full interviews occurs, and supporting field notes were kept (Appendix 2.). To assist with accuracy and research rigour, the researcher kept comprehensive audit trails and records through each step of the data collection, and interpretation process.

Risk vs. benefit

At the core of most ethical considerations for the researcher, was an understanding that we should aim to balance benefits for participants against potential costs or risks (Beauchamp, 2010). While arguably there was an underlying assumption implicit in conducting research that knowledge or increased understanding may be better than not knowing (Grbich, 1999; Liamputtong, 2010; Ramcharan, 2010), there was still considerable tension around ensuring that the benefits of the research for both the

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participants and society at large, would outweigh the potential harms of the research (Robson, 2005; Christians, 2011). While this study, at some juncture, could facilitate broader collective benefits for medical students or junior doctors, Figure 5.1 tables the risks and benefits for individual participants involved in this study. Given the influence of individual experience, psychology, and personality characteristics and traits, not every participating medical student would have experienced each potential consequence. However given the potentially emotionally distressing nature of the topic, and the likelihood that participants may have experienced or witnessed a hostile workplace incident, a list of local counselling services were also offered to all participants. Furthermore, the face-to-face interviews were conducted with a clinically trained social work researcher, allowing for on-going assessment of participant distress during the projects data collection phase. Every effort was made by the researcher during data collection for potential emotional stress of the participants to be minimised. Additionally, it was also acknowledged that the information being shared by participants, particularly when heard collectively, might be emotionally challenging for the researcher. De-briefing was made available for the interviewer whenever it is required.

Benefits . by taking part, a sense of participating in change and activism and having their voice heard. . Gaining knowledge . Increased personal awareness gained from reflecting and verbalising perceptions and experiences . Altruism . Validation and acknowledgment of their insights and experiences Risks . Time commitment . Emotional distress . Psychological unease

Figure 5.1. Potential risks vs. benefit

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Ethics Process

This study had been reviewed and approved by the University of Melbourne, School of Health Science’s Human research Ethics Advisory Group (HEAG) as well as the Behavioural and Social Sciences Human Ethics Sub-Committee (HESC) (Appendix 3.). Ethics approval was granted to the study (Ethics ID 1341085) in February 2014. An application to amend the study to increase the potential participant pool to include all eligible medical students currently enrolled in a Victorian medical school was also later approved.

5.2. Methods

Part two of the research design chapter will focus in detail on the methods employed to address the study aim and questions. The researcher interacted with participants through a wide range of mediums. Potential participants either spoke directly with the researcher on her mobile phone, or emailed their interest. Those medical students who decided to take part in the research, all communicated further with the researcher in one-on-one interviews. A few participants also chose to follow up the interview with additional email contact. Below is an outlining those aspects of research procedures and process, which will be discussed in greater detail. • Target group • Research instrument • Data analysis

Target group

The initial target group for this research is medical students enrolled in one of Victoria’s largest universities. The sample population of medical students enrolled in a Victorian university have been chosen with due regard to current knowledge gaps in related research and literature, ethics considerations, and with the questions and focus of the study in mind. Purposive sampling was employed in order to capture in-depth information, (Carpenter, 2010) specifically the perceptions and experiences of bullying amongst doctors, from eligible medical students. The research adopted a rigorous purposive sampling strategy, which included the use of inclusion and exclusion criteria, thereby ensuring that all participants could contribute in sharing their perceptions,

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conceptualisations, experiences, behaviours, circumstances and insights regarding bullying and abrasive behaviours amongst doctors. The researcher was aware that there was a risk of privileging certain voices over others and as such used language that was considered as non-directive as possible in both the recruitment process and in publically available study information (Daly & McDonald, 1992; Kristensen & Ravn, 2015). As an interpretive or phenomenological study, the target group in this research was selected based on their capacity to inform or communicate the “essence of an experience or phenomenon” (Liamputtong, 2010, p. 128). When considering sampling choices one of the main considerations is whether the sample will provide adequate access to enough appropriately focused data to satisfactorily answer the questions of the research project. Therefore the inclusion criteria stipulated that current medical students would need to have hospital placement experience. University medical faculty staff advised that medical students generally do not have significant hospital placement experience until at least second year, with fourth year being the optimal year level to target. This information was consistent with other relevant studies, such as the exploratory study into medical student abuse (Bourgeois et al., 1993) which targeted 4th year medical students with substantive experience, because “as hypothesized, the fourth year medical students had experienced such (abusive) situations more frequently” (Bourgeois et al., 1993, p. 363). The inclusion criteria were applied to recruitment announcements, and in subsequent contact once a medical student had expressed interest in participating. Furthermore medical students did not have to identify as having witnessed or experienced hostile interactions to be eligible, rather it was suggested in recruitment flyers, that they might have ‘views’ to share on workplace interactions between doctors (see appendices). Whilst exclusion of children under 18 was not explicitly stated in eligibility criteria, the requirement to be a current medical student with hospital placement experience would automatically preclude those aged less than 18 years. Moreover, it was acknowledged that due to language requirements for medical students studying in Australia, participants would need to have linguist competence in the English language in order to participate in the study. This requirement would potentially limit the inclusion of linguistically diverse populations. The inclusion criteria were; • Enrolled in a medical degree at a university in the State of Victoria • Have clinical hospital placement experience

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Participants were made aware, both in writing and verbally, that they were free to withdraw from the study (this was done before they were interviewed), and they were made aware of the timeline and process for withdrawal. In order for informed consent to occur, the medical students needed to be able to base their decision to participate on “full and open information” (Christians, 2011, p. 65). A copy of the informed consent document can be found in the (Appendix 4.). Additional to this, informed consent was further ensured by emailing a plain language statement (PLS) (Appendix 5.) out to medical students when they register their interest in the research. The PLSs were also made available again at the time of interview, and prior to the researcher and participant reading through the project consent form. Moreover, to reduce any perceived disparity in power between the interviewer and interviewee, where possible, interviews were conducted with notice paid to the interviewer’s body language, tone, physical proximity and furniture placement (Harms, 2011). Furthermore, making the PLS available at all times during the recruitment, and data collection process, and answering all questions on the research as openly as possible, ensured transparency, and a research process free from deception. The recruitment strategy of the project included the use of gatekeepers, advertisement, and finally the inclusion of snowball sampling. In order to gain valuable information and rich data, it was essential that potential participants were medical students with hospital placement experience, consequently influencing the choice of gatekeepers and the placement of advertisements or announcements. Initially, recruitment flyers (Appendix 6.) were placed throughout the medical school, medical library and cafeteria at one major Victorian university, however when it became apparent that recruitment was going to be more challenging than originally anticipated, flyers were also placed in another major Victorian medical school. Utilising formal medical student networks, the research recruitment flyers were also sent through to medical student university representatives. As a relatively widespread recruitment strategy in qualitative investigations (Hennick et al., 2011), gatekeepers are often utilised to assist in recruitment. In this particular study, the gatekeepers were the directors of Medical Education Units at two Victorian Universities. An example of the letter sent to one of the gatekeepers can be found in (Appendix 7.). Contact was made by researchers to all four medical teaching facilities in Victoria, two of the four responded positively with an interest in the project. In order to preserve privacy of student contact details, the research recruitment flyers were forwarded by the medical

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unit administration, to current medical students enrolled in year levels three and four. Both Medical Education Unit directors felt that it could be a study of interest to their eligible students. Initially snowball recruitment was not considered as part of the strategy, however as the impact of the sensitive nature of the research became apparent during the recruitment phase, it was clear that new strategies might be useful. Snowball recruitment can be valuable in connecting with hidden or hard to reach participants (Hennick et al., 2011). However, many of the participants opted to refer friends to the research without being asked to do so by the researcher, so that the snowball effect often occurred without the researcher having to request it. As part of the ongoing reflexive nature of the investigative process the researcher used an evaluation of recruitment quality exercise (Figure 5.2), which had been adapted from Hennick et al. (Hennick et al. 2011, p. 105). Other factors, which influenced the recruitment process, were budget, and geographical constraints. The project had no recruitment budget and while it may have increased the diversity of participant pool, there were logistical geographical limitations to putting research announcements up at campuses outside the Victorian capital, Melbourne. The final sample was sixteen medical students, from two Victorian universities. Participants all had clinical placement experience and were from the upper year levels of their medical degree. The sample comprised of 12 females and 4 males. Given the small cohort of male participants, a detailed gendered analysis would not be undertaken, although should themes relating to gender develop, these would have been duly addressed. Further details of the research participants can be found in Chapter Six.

1) Appropriate. Is the number of participants proposed prior, well justified? Are recrtuitmnet strategies suitable for the study population, study location Or cultural context? Are multiple recruitment strategies used and justified?

2) Coherent. Is the study population well justified for the research topic?

3) Transparent. Are the criteria for the study population clearly defined? Is the process of purposive recruitment described? Are the recruitment methods described in sufficient detail? Are limitations of the study population or recruitment strategies noted?

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4) Interpretative. Has purposive recruitment been conducted? Is the study population inductively refined during fieldwork? Is the process of inductive recruitment described?

5) Saturated. Are participants recruited until saturation? How is diversity in the study population achieved?

6) Ethical. Has the participant recruitment been conducted ethically?

Figure 5.2. Evaluating quality exercise

Adapted from Hennick, Hutter & Bailey, 2011, p. 105

Research instrument

Initial data collection ran concurrently with recruitment over a 24-month period, from February 2014 through to December 2015. In order to answer the research aim and core questions, the data collection method that was considered most likely to produce useful, information-rich data was semi-structured, in-depth interviews. The interview context allowed for conversations, and interactions between the participants and the researcher, and was a dynamic ‘meaning making process’ (Darlington & Scott, 2002), because “if we wish to learn about how people see the world, we need to talk with people” (Serry & Liamputtong, 2010). Furthermore, interviews allowed the researcher to capture “areas of reality that would otherwise remain inaccessible” (Peräkylä & Ruusuvouri, 2011, p. 529), areas such as subjective perceptions and experiences. It was determined that the use of in-depth interviews would provide the best quality, rich and thorough data, which in turn would allow a lesser sample size (Carpenter, 2010). Due to the nature of the subject, and perhaps due to the potential fear of reprisal for speaking out, recruitment as mentioned previously was not a straightforward process, however recruitment remained open until data saturation had been achieved (Hennick et al., 2011; Carpenter, 2010). As a clinical social worker who was based in a hospital, and who also taught medical students in a university setting, the primary researcher of this study had acquired years of observations and conversations with doctors, medical students and other healthcare professionals, and had noted that the majority of information-rich details surrounding incidences of bullying or hostile interactions arose during private conversations. Furthermore, in order to see if the research results or findings could have meaning in other contexts, participant realities should be understood in their context (Lincoln & Guba, 1985). Therefore, where

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possible, interviews were confidentially conducted, in the contexts in which the participants generally worked or studied. It was also important that the data collection was conducted in a private, safe, and sensitive manner, as it was acknowledged that talking about bullying and incidents of abrasive behaviours had the potential to trigger emotional and psychological distress for some participants. It was considered that using one-on-one semi-structured interviews was the best data collection approach given the potentially sensitive nature of the subject matter (Hennick et al., 2011). Furthermore with one-on-one interviews it allowed the researcher to capture the participants’ perceptions, views, experiences, and emotions (Serry & Liamputtong, 2010), and guide them to engage in more focused discussion whilst allowing for some spontaneity of dialogue (Robson, 2005; Serry & Liamputtong, 2010). Championing participant confidentiality was enormously important in this research and the measures employed by the researcher to protect participant confidentiality included using one-on-one interviews as the primary data collection tool, using private locations chosen by the participants, and getting the participant to choose a pseudonym at the outset of the interview, so that only the interviewer and the participant knew the real identity of the participant. Moreover, any identifying markers were de-identified, names were written in the file and personal participant data was securely stored with audiotaping to be destroyed after a five-year period. As outlined in the study’s PLS, the identity of hospitals, specialities, units or geographical locations that might identify participants were anonymised. It was noted after the interviews were conducted that while some participants were keen to name the hospitals, particularly when they felt bullying was endemic, the researchers considered that leaving hospital names in may compromise the confidentiality of participants. Therefore single letters such as ‘A’ or ‘S’ were assigned to hospitals. Prior to the Ethics Committee review, the questions on the interview schedule were given a trial run through on a number of occasions and the time commitment it was likely to take around 20 to 30 minutes. Actual interviews end up ranging between 20 minutes and 90 minutes, with most interviews sitting around the 60-minute mark. A visual representation of the data collection process can be found in Figure 5.3.

Data collection process

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Purposive recruitment campaign of participants  Potential participants contact researcher via mobile phone or university email  Initial contact from researcher made to the potential participant. Checking eligibility and equipping medical student with PLS and Consent form.  If participant is still interested and available, a time is made for an interview The participant nominates a time and place in conjunction with the researcher – who has a number of private environments available to offer students.  Researcher meets with participant. PLS discussed and Consent signed [if not already done electronically]. Interview commenced. List of relevant support and counselling agencies offered. given for the participant to receive an update on findings of research and options discussed for withdrawal from research.   No further contact Outcomes/Findings emailed at end of research process  Or no further contact from participants regarding additional information or other possible participants Figure 5.3. Flowchart of data collection process

Interview guide

During the development of the interview guide amendments were made to language choice after initial consultation with laypersons, with the aim to keep the language of the document as non-technical or jargon-free as possible. Furthermore, inductively there was minor rephrasing, simplification or reconfiguration of some of the questions in the interview guide as it became apparent that participants were overlooking part of the question being asked. In the original interview guide Question 6 asked, “Do you think your workplace or profession has a particular culture relating to workplace intra- colleague interactions? Tell me more about that culture. How would you describe it”. As a result of the first few participants requesting to have this question clarified and the

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concept of workplace and profession explained, a subsequent interview guide investigated the issue by using two separate questions, asking instead, (Q4) “Do you think that hospitals have a particular culture relating to work based exchanges/communications between doctors? Tell me a bit more about that culture. How would you describe it?” and (Q5) “Do you think that your profession (medicine) has a particular culture relating to interactions or exchanges between doctors?” Moreover, eventually the original terms intra-professional and intra-colleague were exchanged for simpler terms such as ‘hospital-based interactions’ or ‘exchanges between doctors’. Both the interview guides can be found in the (Appendix 8.), listed as the original interview guide, and the amended interview guide.

Interview process

The interviews were planned utilising the guideline of a typical sequence (Serry & Liamputtong, 2010) of introduction, interview body and post-interview de-brief. During the introduction phase, rapport was built, and the researcher introduced the participant to the purpose of the study, reassuring them on confidentiality, and checking through the consent form to ensure it had been read and signed. During this time, the researcher also checked with the participants to see if they have received and read through the PLS. If participants had further questions regarding the study, they were invited to ask questions at any time during the interview process. The researcher reiterated that there were no ‘right’ or ‘wrong’ answers to any questions asked, and that they always had the right to interrupt or seek clarification at an time. Although already outlined in the PLS and consent forms, permission was sought to audiotape the interview, whilst explaining that the recordings were to ensure accuracy of content. During the introduction phase, the participants were also given the option of requesting a copy of the transcript to verify the information or request deletions. An estimate of the time it might take for the interview was given, as were the reassurances that participants could take a from the interview process should they feel distressed, additionally a list of resources or supports were also available. The interviewer was cognisant at all times, of reducing any perceived participant risk, during the interview process, and was able to employ question pacing, water breaks, and specific communication practices such as smoothing or containment skills if necessary (Harms, 2011). That the participant was free to withdraw from the interview process,

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and to withdraw any unprocessed data gathered during that time was also reiterated. In most interviews during the introduction phase, participants also asked questions of the interviewer, often asking about the research and about the interviewers own professional background. During the initial interviewing phase participants were asked a series of direct demographic questions (Appendix 9.) which aimed to gather information regarding age group, gender, country of birth, race, ethnicity, familial or friendship connections to medicine, as well as formal occupational title in their last hospital placement, and a self ranking in terms of position within the organisational and professional hierarchy. While the body of the interview guide was semi-structured in nature, the demographic questions asked were closed in nature, and allowed for the interviewer to gain some context or background about the participants, as well as assisting in the rapport building process (Hennick et al., 2011). The key concepts phase of the interview was broken into three core areas, organisational and professional context, your experiences of hospital-based interactions or exchanges between doctors, and understanding negative intra-professional workplace interactions. Within the interview guide, the first core concept area, organisational and professional context comprised of six questions. These questions aimed to explore the participant’s sense of professional and organisational self, and their conceptualisation of their hierarchical ranking within medicine. The questions had been generated in part from broader workplace bullying studies and healthcare literature that had considered a connection between dynamics of professional and organisational power and hostile or bullying behaviours. These initial core questions were also seeking to clarify and understand better, the nexus between an organisation or institutions unique culture and perceptions and experiences of bullying. The opening questions were deliberately less emotive in nature, and constructed to focus on broader contextual issues, that were considered more likely to build on rapport (Hennick et al., 2011) and less likely to induce emotional distress. The six organisational and professional context questions in the interview guide were:

Organisational and professional context 1. Do you think of yourself as a trainee doctor, doctor, or medical student? 2. Does this differ to how others might perceive you, personally and professionally? How so? Prompt: inclusive of other professions etc.…

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3. Do you feel you have an ability to influence others? Who and how? 4. Do you think that hospitals have a particular culture relating to work based exchanges/communications between doctors? Tell me a bit more about that culture. How would you describe it? 5. Do you think that your profession (medicine) has a particular culture relating to interactions or exchanges between doctors? 6. Are you aware of any hospital policy or regulations around employee interactions? What behaviour do you think it specifically relates to?

The second core concept area within the key concepts phase of the interview aimed to explore the participants’ individual experiences of exchanges or interactions between doctors. It was made clear in the recruitment phase, and was reiterated again in the interview process that participants did not need to have experienced or witnessed behaviours that they considered or labelled as hostile, abrasive or bullying. Therefore, the second key concept area asked participants to characterise their everyday or ‘ordinary’ interactions between doctors, as well as any other hostile interactions that they may have observed or experienced directly. These questions were prompting the participants to describe and share exchanges amongst doctors, and to gauge their personal insights and conceptualisations of those behaviours. There were six questions in this part of the interview guide, however, this particular stage of the interview often elicited rich, expansive responses from participants and further supplementary questions or probes were sometimes employed by the researcher to gain a fuller understanding of the participants nuanced perspective or experience. The six questions based on the participants experiences or observations of hospital-based interactions or exchanges between doctors were:

Your own experiences or observations of interactions between doctors 7. How would you characterise most of your daily interactions with your medical colleagues? 8. Have you ever been involved, or witnessed a hostile or abrasive interaction with another doctors? 9. What did the behaviours or actions look like? Prompt: actions, behaviours or words.

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10. How did this incident make you feel at the time? Prompt; emptions, reaction, i.e. not bothered, distressed, confused… 11. Has that feeling changed? If so, how? 12. What label (if any) would you use to describe the incident and why?

The third core concept area within the main body of the interview phase involved understanding the participants’ conceptualisations of negative intra-professional workplace interactions. The aim of the questions in this segment of the interview guide was to elucidate a better understanding of how medical students might conceptualise bullying amongst hospital-based doctors. As established in the earlier chapters, research indicated that the notion of subjectivity, and choice of label or definition were central in how individuals perceive, construct and ultimately experience incidences of workplace bullying. In order to fulfil the overall aims of the study, it was valuable to ask questions, which directly gauge how medical students individually define, as well as understand or construct the causation of hostile interactions amongst doctors. Moreover, it was the intention that the questions in this section of the interview guide assisted the researcher to better understand medical students perceptions regarding formal reporting of abrasive workplace behaviours amongst doctors. This was done with a series of four broad questions as well as five questions linked directly to a hypothetical case. The hypothetical was based on workplace bullying definitions found in legislation and regulation, and an amalgamation of observations during the researcher’s work as a clinical social worker, anecdotal stories by medical students and doctors, and published studies on abuse of medical students. The use of hypothetical case scenarios or vignettes has been established in previous comparative studies (Bourgeois et al., 1993; Ogden et al., 2005).

The hypothetical and its linked questions are as follows.

13. I am going to ask you to read a hypothetical workplace interaction between two doctors.

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Hypothetic case scenario

A senior doctor shouts at a junior doctor for not answering their questions quickly enough. They do it in front of other staff and patients. This happens on a fairly regular basis, and the junior doctor is starting to question their own capacity to one day be a competent doctor. At times the junior doctor feels humiliated, and where possible, they have started avoiding interactions with the senior doctor. The questions participants are then asked in response to the hypothetical case scenario are: 1. What thoughts or emotions do you have on the behaviour of the senior doctor? 2. Would you describe the senior doctor’s behaviour as acceptable, or justifiable? 3. If you felt the senior doctor’s behaviour was not acceptable in this scenario, are there any circumstances in your workplace where you’d consider that this behaviour might be justifiable? Try and describe that scenario for me. 4. Some might consider the behaviour of the senior doctor to be workplace bullying, what do you consider the behaviour of the senior doctor to be? What words or labels would you use to describe the senior doctor’s behaviour? 5. Is there any other information about this scenario that you would want to know before you would label it as bullying? What is it?

After the participant had read through the case scenario, and discussed the five associated questions, the researcher asked four broader questions. These four questions included:

Understanding negative intra-professional workplace interactions 14. Can you think of a time in your professional life where you chose not to report a hostile or abusive interaction with a colleague? What happened? 15. Can you think of any reasons that the target of a hostile interaction between doctors might tolerate the behaviour, or not report the incident? 16. Why do you think that bullying might occur between doctors? 17. Do you feel that your perception of behaviour by other doctors as acceptable or unacceptable has altered over time? How?

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The ending phase of the interview guide indicated that there was no further key questions, but allowed the participant to add anything further by asking the final question:

To finish 18. Is there anything else you’d like to discuss in relation to this topic?

Closing an interview thoughtfully was important, allowing for a slow reduction in rapport that is built up over the course of the interview (Hennick, 2011). In this phase of the interview, the participant was thanked for their time, reiterating the researcher contact details if they had any further questions, as well as the availability of the list of resources and supports if they found the discussion emotionally distressing.

Interview logistics

The interview was audio-recorded with participant consent. The interviewer followed the interview guide and there was a hard copy of the questions made available for the participant to read if they were interested in doing so. Field notes or researcher memos were also taken at the time of the interview. All but two of the interviews were actually conducted face-to-face; the exceptions were for two medical students on remote rural placements, and for those two interviews, they were conducted on mobile phone, via speakerphone allowing for the consented audio-recording. Initially a professional transcriptionist was employed to transcribe the interview recordings, however the primary researcher also went through a number of the interview transcriptions and cross-checked the transcriptions with the recording to ensure rigour and authenticity. A number of discrepancies were found in the transcriptions made by the professional, which resulted in the primary researcher going back through all of the interview recordings and cross-checking and rectifying any of the misinterpretations within the transcriptions. Pseudonyms were used on these transcriptions with the real names and identities of participants known only to the researcher and the participant. Locations and times of the interview were dependent on what the participants felt comfortable with, and ranged from the kitchen bench of a medical student through to a quiet space in the public hospital where the participant was on rotation.

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Data analysis

Thematic analysis was performed on the transcriptions of the interviews, using a systematic approach of coding that ensures that the themes identified stay as close as possible to the data itself. As identified earlier in the chapter, each aspect of the research process should transparently be acknowledged as a deliberate choice of the researcher (Braun & Clarke, 2006), and thematic analysis was considered by the researcher to be the most fitting choice of analysis for this investigation. Defined in Braun and Clarke, thematic analysis is “a method for identifying, analysing and reporting patterns (themes) within data” (Braun & Clarke, 2006, p. 79). Whilst largely inductive in nature this process of analysis also recognises the active role that the researcher had in framing the questions asked and identifying and choosing the patterns or themes within the data (Braun & Clarke, 2006). In order to privilege the research’s ethical obligations of accuracy and rigour, data interpretation was done using a thorough six-phase analysis process (Braun and Clarke, 2006), where codes, and themes were produced through analysis of the entire data set. The researcher worked systematically through all the interviews giving complete and equal attention to each interview. The researcher determined how a theme was defined, not necessarily by the significance or weight that the participant themselves may have put on an issue, but rather on the issues appearance and reappearance across the data set. Additionally, within this project a theme is considered an issue that “captures something important in relation to the overall research question” (Braun & Clarke, 2006, p. 82). In alignment with the rest of the research design, the data analysis was constructivist in nature, accepting the paradigm that the participant’s realities, experiences and perceptions were the product of a multiplicity of societal based discourses. Of the 16 interviews conducted, the transcribed content of all 16 of them were used to form the data set analysed. The process of data analysis used in this project followed very closely Braun and Clarke’s (2006) six phases of thematic analysis. These six phases are outlined below in Figure 5.4.

Phase Process 1. Appraising and familiarising data Transcribe, Read and re-read interviews. Jot memos down on transcriptions. 2. Generated initial codes Systematic recording of features or issues

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noted across each data item (interviews) and then the entire data set. Assembling interview data related to each code 3. Theme search Bundle codes into possible themes. Gathering any data pertinent to each potential theme. 4. Theme review Cross-check that themes are congruent with initially coded transcripts and then across entire data set. 5. Defining themes Refining theme specifics, definition and them name generation. 6. Report production Final phase of analysis, where extract selection occurs, and writing up of results during the research process. Production of rigorous academic report.

Figure 5.4. Table of data analysis phases

After the interviews were read, the initial stage of phase two of data analysis can be found in the excerpt of Amelia’s interview below. All interview transcripts were processed in the same manner.

Interview of Amelia: Focused coding

Age 20 -29 Female Country of Birth: Australia Sri Lankan Family members who are doctors: “ a couple of cousins” [06.16]

Organisational hierarchy + Perception of status/ occupational title and resulting treatment by others

“Haha, at the bottom of the food chain”[6.36]

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[6.53] “Umm…look we are here to be educated, we certainly don’t get any responsibility, so I think we are expected to learn from our superiors and to look up to them”

[7.27] Participant thinks of herself as a “Medical student. At times a trainee doctor but predominantly medical student”

[7.39] “I think some of them [fully qualified] see you as students and will ignore you. Where others will value you as an investment as a trainee doctor”

Participant reports their ability to influence other is limited [08.01]“my medical student peers, not doctors”

Hospital and professional hierarchy + unwritten rules and limitations on interactions between senior and junior doctors

[08.23] “Look I think there is a hierarchy. I think it is difficult for junior doctors to challenge or to…ummm they can ask a benign question but there is a limit to the amount of challenging that you can do of senior doctors”

[08.38]“I think often they [senior docs] will set the tone of the conversation and…it sort of an unwritten rule…you know this is hierarchy and you kind of have to observe it””…some senior doctors really do go out of their way to make a comfortable environment and not seem elitist”

Additionally, Figure 5.5 is also an extract from the latter part of phase two of the data analysis process. In this step, each interview was read through repeatedly and initial codes were generated. Each code was then ascribed a colour. The initial coloured codes from the entire data set were then combined and the researcher moved into phase three and four of the data analysis process. The process was not necessarily linear in , and the researcher also moved back and forth, particularly between phases two and five. This systematic cross-checking between the original transcripts, and different stages of code developments ensured that any themes generated were as accurate and close to the data as possible.

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Figure 5.5. Extract from the final part of phase two of data analysis

Phase three of the data analysis process, where codes were refined into themes is illustrated in Figure 5.6. This figure is an extract of a record where the researcher was distilling and bundling codes identified in the data set into initial themes. This ‘code to themes’ document was part of phase 3 of the data analysis process.

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Codes to themes Hierarchy and power (hospital, professional, power, status, influencing others, importance of powerful allies, using hierarchy to gain advantage, rigidity of hierarchy, identifiers of medical power, body language and power) Impacts of bullying, hostile, abrasive behaviours and environments (mental health consequences, fear, dehumanisation, professional and personal humiliation, undermining confidence, career repercussions, impact on patient, feeling inconsequential, impact of system and process rigidity, loss of identity) Communication between doctors (communication with other health professionals, teaching, mentoring, chain of command communication, rigidity of communication structure, the art of speaking to someone professionally senior, rules of communication, informal communication, unwritten rules) Interactions amongst doctors (ignoring, inclusion, mentoring, abrasive, lack of respect, importance of following rules, experiences of hostile interactions, bystanding, reporting and not sticking your neck out, positive interactions, friends vs. colleagues, lack of accountability for interactions and behaviours) Conceptualisation of bullying and abrasive behaviours (broader influences, individual influences, organisational and environmental influences, historical influence, victim’s fault, criteria for definition, media influence on bullying and hostile behaviours, humour and bullying) Knowledge and intelligence (intellectual snobbery, importance of being right, need for doctor’s omnipotent knowledge, ‘being right’, value of intelligence, teaching, admitting you don’t know, intellectual humiliation, mistakes and fear, lack of knowledge of formal hospital policies and regulations, unrealistic academic and skills expectations) Generational impact, hope, change and the future (cycle of abuse, right of passage, ring of fire, impact of age on behaviour and acceptance of behaviours) In-defence of medicine (behavioural and professional caveats, qualifications, bad day defence, busy defence, reframing hostility as ‘ a lesson ‘ or a ‘misunderstanding’) Duplicity (professional and organisational culture, two-faced subtlety of behaviours) Sexism and discrimination (gender impact on WPB behaviours, sexism in medicine, conceptualisation of sexism as bullying, changing sexism, jokes, sexism in surgery, sexual harassment in medicine, impact of age and sex on sexism)

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Characteristics of the profession (medical culture, culture of acceptance, learned behaviours, lack of support for medical students, pervasive medical culture of abrasive behaviours and , individual doctors personalities, professional culture of acceptance, professional enculturation, time, sexual relationships between doctors, stigma, exploitation of medical students, overtime, professionalism, not misrepresenting yourself professionally, high work loads and high stakes tasks, informal professional process and culture, tribes, importance of image in medicine, competition, tough culture of medicine, culture of privilege, professional identity, camaraderie of medicine) Cultural silos (organisational, professional, unit, individual and specialty – impacted by process, established systems, individual personalities, rules, protocols, guidelines, accepted norms, tasks, focus, stressors, communication styles, history, broader hospital agenda or mandates) Characteristics of the organisation (organisational enculturation, hospital culture, imperative of time, abrasive workplace cultures, why organisations still retain known bullies, organisational culture of , workplace happiness, city vs. rural, rigidity of process and interaction, hospital obligations to employees, lack of institutional support, inadequate organisational response, differences of organisational characteristics between countries) During phase four of the data analysis process, themes were reviewed and refined, and many of the initial themes identified in the entire data set were collapsed into three broader, or overarching themes. During the theme refining, defining and naming phases (phases 3 to 5), each of the three broader themes were allocated colours and the sub themes were then assigned one of the three colours, thus eventually identifying them as belonging to either, beliefs, behaviours or context. Phase 6 of the data analysis process included writing up, and multiple presentations of this research thesis.

Figure 5.6. Codes refined into themes

5.3. Chapter summary

This chapter has explored all aspects of research design, including methodological, ethical, procedural and logistical considerations. This chapter illuminated the projects congruity between the underpinning research paradigm, the research questions asked, and the methods employed. Using a constructivist lens in the research has meant that the project championed the opinions, experiences, and perceptions of the purposively recruited participants, and that those lived experiences and insights of the medical students were best discovered utilising qualitative methods. Using interviews as a data collection tool has allowed the researcher to learn the participants’ feelings and conceptualisations, using their own words, and allowed for the participants to explore and elaborate on the meanings of questions and answers. The following three chapters

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share the data gathered, and the insights of the participants, as well as expanding on the themes that have been identified within those interviews.

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Chapter 6. Introducing the research participants

In Chapter Six, the beliefs that medical students shared on a range of issues relating to bullying amongst hospital-based doctors are presented. This chapter initially outlines participant demographic profile, along with their identified familial or social connections to the medical profession, followed by perceptions of hierarchy, and a description of the participants’ perceptions of self. Participant beliefs on hierarchy and perceptions of self, link with research question three, which focuses on our understanding of power and oppression dynamics. Some of these conceptualisations or beliefs shared by medical students are overt in nature, while others are more concealed within the responses given in the interviews.

I was really keen to participate because I have seen a lot of things that are really poor practice and the culture on medicine does need to change and I guess I feel like a lot of its negative interactions really contribute to poor mental health in medical students and new doctors. – Matilda

6.1. Demographic profile of participants

The table below outlines the details of the 16 participants, starting with their chosen names, at the beginning of each interview, participants were invited to choose his or her, own pseudonym. Names were often chosen to reflect the participants’ literary, film or musical idols, or simply names they had always coveted. An example of this is the pseudonym, ‘Dr Nick Riviera’; the name of a character from the T.V show, ‘The Simpsons’.

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Table 6.1. Participant demographics

Age Country of Familial Pseudonym Sex Ethnicity range Birth connection Abigail 20 - 29 Female Australia Jewish Yes - multiple Amelia 20 - 29 Female Australia Yes - multiple Ashley 20 - 29 Female Australia Caucasian Yes - nurse Basil 20 - 29 Female Iraq Arabic Yes - Christine 20 - 29 Female United “Australian” None Kingdom Chuck 20 - 29 Male Australia Indian Yes - multiple Hadley Over 30 Female Australia “Australian” Yes - multiple Lily 20 - 29 Female India “Australian” Yes - Mathalda 20 - 29 Female Australia Caucasian None Matilda 20 - 29 Female Australia Caucasian Yes - multiple Nick Riviera 20 - 29 Male Australia “ABC - None Australian Born Chinese” Oliver 20 - 29 Male Australia Caucasian Yes - dentist Sally 20 - 29 Female India Australian/Indian None Steve 20 - 29 Male United Caucasian Yes – Kingdom multiple 3rd Generation Teddy 20 - 29 Female Afghanistan Afghani Yes - friends Rhianna 20 - 29 Female Australia “ABC” None

The participants as a collective

While the demographics of medical students as a general cohort are discussed in greater detail in Chapter One, section 1.2, this paragraph specifically unpacks the demographics of the medical students who participated in the study. Fifteen of the sixteen students were within the 20-29 age range, which is unremarkable compared with the general medical school population. Of the 16 research participants, 12 were female (75%) and 4 were male, which flags an oversubscription of females compared to the general medical student cohort. The country in which participants were born mirrors the broader Australian medical student cohort, with comparable rates of students born in Australia and overseas. As part of the interview process, participants were invited to nominate a race or ethnicity that they identified

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with. No participants nominated themselves as Indigenous Australians. Given the low Indigenous participation recorded in Australian medical schools, this finding is unremarkable. Participants were asked if they had any significant family or friendship connections to the medical profession, with most of them citing strong familial connections (see Table 6.1). There was no accessible data available on the broader medical student cohort, which could be used to compare with the participant specific connections. Some examples of these connections are as follows. When he graduates Steve will be a third generation doctor, “Father, grandfather, , cousin, and friend, friend, friend”. Basil said, “Yes. My father, and my mum’s a dentist as well”. Amelia noted she has “a couple of cousins”. And Hadley said, My Brother-in-law, half uncle”. Abigail shared that a lot of her family were doctors, and that they often discussed ‘all things medical’ at the dinner table, “Family, dad, aunty, uncle, cousins, friends, most of my best friends, ”. Lily talked about the example her mum set for her as a general practitioner, “So many. There’s my mum, she’s a GP, so many of my close friends are either Interns or Residents, or Registrars”. Other participants had no medical connections. Ashley noted, “Nil. My mum’s a nurse but that’s it” and Christine said, “No friends outside colleagues”. There was also some discussion around how broader influences such as family, might have influenced the participants’ conceptualisations and experiences of bullying amongst doctors. Lily shared that her mum never influenced her in her decision to become a doctor,

I independently came to the decision that I wanted to be a doctor. So there wasn’t… even then mum was like ‘are you sure, it’s kinda hard’, and I was like yeah I know, I want to do it.

And Oliver noted,

I’ve got family friends who are doctors and I guess the way I’ve been brought up is not to let that hierarchy come into mind, but undoubtedly it does when you come to actually study in medical school.

Steve spoke often throughout the interview of his strong medical connections, “I mean I knew the yelling and all that occurs. I told you before I’ve got family that are in

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medicine, I’ve watched movies”. Abigail shared her thoughts on having a child start in medicine,

There’s a big difference coming from a medical family and a non-medical family, non- medical ’ medical students are you just like “ohhh (wow)’, medical students from medical families just don’t care at all.

6.2. Conceptualisations of hierarchy

All the participants had experienced more than one clinical rotation, and were able to articulate in exacting detail, the level of their own perceived hierarchy and influence. Furthermore, a number of the students were able to connect one’s professional title or label with their level of organisational and professional influence. Additionally the medical students perception of their hierarchical status may feed into a theme that came through during the coding process, on the importance of your projected image. This is encapsulated in an observation by Christine who said, “I feel very much, how people perceive me is sort of how I project myself, so if I am confident and keen and seem to know what I’m doing, I feel that generally I’m treated respectfully and appropriately”. Many participants also articulated the belief that the most senior doctor sets the whole tone for the other workers. For example, Christine said, “if the consultants at the top of that unit are, um, you know, imposing…like setting the tone, I feel that that trickles down to the registrar, the residents and the interns…the fish rots from the head down”. Research indicates that recognising a worker’s perception of their own workplace authority and ability to influence others is central to understanding the phenomenon of workplace bullying (Tuckey, Dollard, Hosking & Winefield, 2009). This raises the question as to how an expanded understanding of perception of hierarchy can add to our current knowledge on why a medical student might feel bullied, why that bullying might occur initially, and why it continues to be perpetuated within the hospital. Further to this, however, the medical students’ own conceptualisations of hierarchy gave fresh insight into how they make sense and give meaning to concepts such as professional and workplace rank, status, power, and hierarchy. This insight may contribute to a more nuanced awareness of the interaction between power, and hierarchy and the medical professions conceptualisations or acumens on workplace bullying.

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Perceived organisational rank

All the participants were very clear that there was a well-defined organisational hierarchy, illustrated in Steve’s comment: “certainly there is hierarchy of medical staff in hospitals”. Furthermore, all participants were clear on where they thought they fitted into the organisational hierarchy. All the participants indicated, through language choice, that they were towards the bottom of the chain-of-command. Many of the students, laughed and gestured in a manner indicating that their answer was inevitable. Rhianna said,

probably near the bottom. I think there’s …it sort of goes like, you’re a doctor, you’re allied health, doctors and nurses and allied health…then like the cleaners…various people…. and then there’s the medical students.

Christine noted she was “Pretty much right down the bottom I think”, and similarly, Abigail noted she was, “In the medical field, lowest of the low, lower than anything else”. Matilda got straight to the point with her response on the issue of perceived organisational rank, “At the bottom”. Amelia used the analogy of a food chain, “Ha-ha, at the bottom of the food chain”. Oliver addressed the issue of organisational hierarchy with humour, and suggested that he was “umm…top…Noo, hahaha. Probably the bottom, yeah definitely the bottom”. Some participants believed that organisationally they were ranked so low that they didn’t actually figure on the organisational hierarchical scale. For example, Steve said he was “sort of, to be honest, outside of it”.

A few of the other participants were very precise in their perception of where they sat on the hierarchical scale, both within the organisation, and the profession, Mathalda shared, “A little bit above the third year and a lot below everybody else”. Dr Nick Riviera said “Towards the bottom, almost at the bottom but higher than the 2nd and 3rd years, and the nursing students actually. Maybe two or three rungs from the bottom”. Teddy reported that “being a medical student you are sort of right down the bottom and you need everyone else’s help to get around the hospital and do things”. Being reliant on others for access to everyday workplace functions or processes, such as computer access or car parking, was considered a criterion used to figure out organisational ranking. Other participants had different ways to figure out their organisational authority, with Sally suggesting,

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Basically we are always the people who have to accommodate I guess, for everyone else. I feel like we spend a lot of time waiting for other people…just knowing the steps to come, you know, medical students, intern, resident, that sort of, is a very solid way of describing hierarchy that you cannot escape.

Sally elaborated, “Because the hierarchy is so strong and distinct, you place a lot of faith in the doctors who are senior to you. You are quite dependent upon them, both personally and professionally”. Hadley reported that she used the “level of training and level of experience” to measure someone’s organisational and professional hierarchy. Linking low organisational authority with ability to influence, Sally suggested that within her current hospital placement her ability to influence others was “I wouldn’t say never, probably not very often”. A number of participants reported an increase in perceived value or professional authority as they rise through the years of training. Matilda shared that,

I feel like I don’t really have much influence. Although in saying that this is like my first rotation in my final year and I found as a final year student that sometimes my input is sought more than it has been previously.

Dr Nick Riviera stated that, “The Registrar actually takes into account my suggestions”. The responses flagged a complexity and individuality in the evolution of skills and professional capacity, which appears to develop over the years of practical experience and knowledge acquisition.

Perceived professional hierarchy

Similar to the concept of organisational hierarchy, every participant was clear that they felt they were at the bottom of the professional hierarchy. Additionally, a number of participants described that ranking and status was established early within the profession of medicine. As Dr Nick Riviera suggested, “We got ranked within our year, I’m towards the bottom of the year”. Oliver also reported that he is higher in professional status than the more junior medical students “I mean even in medical school there’s hierarchy and I think that just continues on into the profession of a doctor”. Christine said, “So probably still at the bottom but at least higher than the MD2’s I guess”, although Hannah suggested, “I don’t think the first years are any worse off than the MD4s for example”. Teddy noted, “I mean we’re not even qualified

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so again right at the bottom”. And Abigail suggested that in medicine “post Grad students are treated much better than the under grad students”. Ashley said that she would rank her professional standing as, “Oh right down the bottom. Like right down the bottom”. Abigail echoed this also in saying, “In general, in the medical field…lowest of the low, lower than anything else”. Some participants had experience as medical students in overseas hospitals, and noted a difference in organisational hierarchy. For example, Rhianna noted: “Even though there is that sort of hierarchy (in Australia), there’s definitely not as much as what they have in Asia”. There was a very real sense from the participants that within medicine and within a hospital, with time (and the experience that it brings), that it was possible for those at the bottom of the hierarchy, that is medical students, to advance through formal ranks. An element of inevitability crept into students’ responses, in an acceptance of the rigid professional and organisational hierarchical status, and the anticipated parallel professional, social or relational status that each rung on the ladder would bring. Mathalda identified at the bottom of her profession but was “working on it”. Sally also noted,

there is a tendency to congregate within your own field, so doctors will congregate together, medical students will congregate together, nurses will congregate together. Even within our hierarchy I guess, interns, doctors, registrars will stick together.

A couple of students also noted a hierarchy within medical specialties, with Steve stating, “I mean there is certainly a hierarchy amongst doctors of you know consultants from the top. Like I said ED, emergency doctors always seem to cop the worst rap”. Amelia also acknowledged,

Look, I think there is a hierarchy. I think it is difficult for junior doctors to challenge…they can ask a benign question but there is a limit to the amount of challenging that you can do of senior doctors.

While most of the participants suggested that there was a link of some sort between a strict formal hierarchy and abrasive behaviours, one participant, Mathalda, summed it up with pointed clarity:

It’s a correlation, I’m not sure it causes it, I think it maybe just the bullying is able to occur because it’s very hierarchical and you’re not friends with your colleagues. If you’re friends with your work mates you’re not going to get bullied.

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Given their position of low organisational and professional rank, it was unsurprising that the participants suggested that in most instances they felt that they have very little ability to influence others. Some participants, such as Basil, suggested that her ability to influence depended on who that person was, “Depending on who they are. Consultants, probably no”. This sentiment was echoed by other participants, who similarly reported that the higher up the hierarchical ladder, the less likely they were to be able to exert meaningful influence. Moreover, there was a high level of congruence between the research participants’ perceptions of their professional and organisational authority and perceptions of authority from participants in a comparable study (Gan & Snell, 2014). Medical student participants in the Gan and Snell (2014) study reported a high degree of powerlessness versus feeling empowered, with one participant suggesting:

The thing I think corrodes people over the year and a half of clerkship is the sense that when they run into stuff that is bad, they can’t change it or the faculty isn’t behind them to change it…that lack of power to students…and the lack of voice for students in the faculty is actually a huge problem (Gan & Snell, 2014, p. 612).

Perceived low power status, lack of organisational and professional authority and support, coupled with a perceived lack of rights or entitlements and increased job stress was encapsulated in the previously referenced Job Demands-Control-Support model, which is sometimes used to explain causation of workplace bullying (Tuckey et al., 2009).

What is in a name: The vexatious issue of professional title

Interestingly, many of the participants were not always clear on what their title was, either outside the hospital, or even within a clinical placement. While clarity of role is important in reduction of bullying incidences (Caponecchia and Wyatt, 2011), the nuanced and numerous , which were immediately identified by the research participants, along with the accompanying workplace and professional consequences of that title, spoke to the embedded nature of hierarchy and power within the medical profession and hospital systems. Below are five representations of the manifold and sometimes conflicting self- perceptions.

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Dr Nick Riviera said, “Oh God … I’m either a medical student or a research assistant, depending on who you actually talk to”. Dr Riviera’s hospital I.D badge reportedly says “Medical Student” yet he thinks of himself as a “trainee doctor”. He said,

At the moment I’m being treated as a doctor or a trainee doctor. Since I’m in the last half of my final year, most of the clinical staff also treat me as a trainee doctor, to put it in their words, ‘this is the period where you learn not to kill someone’.

Christine reported that her hospital badge said ‘Medical Student’ but,

I interchange medical student and student doctor, depending on who I’m talking to, but I find with some people if I tell them I’m studying medicine they’re actually not sure the end result of that is becoming a doctor, so sometimes student doctor, it makes sense to people.

Matilda also noted that her hospital badge was labelled “Student Doctor” but she identified as a “trainee doctor” although, “other qualified doctors would consider me to be a doctor in training”. Mathalda suggested that her badge was labelled ‘Medical Student’ but she identified “this year… trainee doctor”. Several of the participants responded to the issue of title, which indicated that professional title was important in a hospital setting, and that misrepresentation can be either advantageous to the way you are treated, or a potentially dangerous liability. Sally identified as a trainee doctor, but said,

Professionally there is a bit of variety, I think you do get doctors who still see you as medical students but this year I feel like I have noticed more that you are sort of…just on wards and interactions with nurses and allied health staff, you can be more likely to be mistaken as an intern, than you would be as a medical student.

Steve reported that his badge says ‘Medical Student’ and he suggested

we have to think of ourselves as medical students because we can get into some issues if we call ourselves student doctors, young doctors, new doctors, learning doctors, that sort of thing…we find that a lot of the doctors and even the nursing staff will call us student doctors and that kind of thing. I think of myself as a medical student, and I introduce myself as such but not everybody agrees with us.

Rhianna shared that her title was,

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‘3rd year medical student’ and that her hospital badge said ‘medical student’. It is literally like a warning sign, a red flag…I think it’s a new initiative of The A. Hospital, and it’s good because it means that people know from a mile away who we are and who’s coming.

Steve also noted,

if a doctor introduces us as student doctors, there is a different level that the patients expect us at, and so they seem far more willing to, you know, talk to us and that sort of thing, as opposed to if you are introduced as a medical student.

Basil said that some family and friends “think I am a doctor already, which is very uncomfortable. Professionally, the patients think that I am a doctor already as well, but the doctors don’t, which is good”. These responses illustrate how the medical students were grappling with the need to be transparent and safe in providing care for patients. But they knew in doing so, they risked losing the respect that comes with being mistakenly identified as someone who is a more senior, fully qualified doctor. These responses also picked up on the implicit respect that is given to doctors by the general public, and this was reflected in the way that family and patients responded to students when they thought they were fully qualified doctors. Chuck noted this career point:

I’m at the point where I have almost enough knowledge and skills to you know, be an intern and be a doctor, but at the same time know that there are restrictions and limits to what I can do and also the fact that I am a student means that I can’t sign anything, so it’s technically lower than mentally.

He then continued on to say that patients “are told that I’m a trainee doctor by the other doctors, so it’s more towards a doctor than a trainee doctor”. For this 5th year medical student, Chuck, telling patients he is in training was “something that I say because I have to not because I like to”. Amelia labelled herself as a “Medical student. At times a trainee doctor, but predominantly a medical student, however she insightfully articulated the power difference inherent in professional titles, by reporting, “I think it will vary depending on the doctor. I think some of them see you as students and will ignore you, where others will value you as an investment as a trainee doctor”. Explaining the value of forming relationships in medicine, and the status embedded in different titles, Lily advised that,

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“you’re a medical student, but to be called a ‘trainee doctor’… I feel like you’ve kind of got to earn it in their eyes”. Only one student identified as having congruence between how she perceived herself professionally and how others within medicine perceived her. The student, Abigail, said she identified as a medical student and “others see me as a medical student”. Participant responses indicated an early establishment of the importance of professional title, and the correlation between growing professional confidence, title, and professional, organisational and wider social status. The responses also captured the dual complexity and importance of a medical student’s titles when on clinical placement.

6.3. Chapter summary

Whilst the participants themselves were drawn from diverse demographic backgrounds, the results in this chapter indicate a range of commonalities in their perception of organisational and professional hierarchy. Chapter Six also illuminated that elements of professional and organisational ‘hierarchy’ had the capacity to colour the way in which the medical students conceptualised their own role in incidents of bullying. Finally, the professional title often bestowed on the medical students during clinical placements illustrated the dual complexity of, and significance that hierarchy played in their experiences of bullying. The next chapter will explore further the participants’ shared insights on perceptions of bullying.

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Chapter 7. Perceptions of bullying

Chapter Seven includes an exploration of the participants’ beliefs or perceptions on the intergenerational nature of bullying, contributions or cause of bullying behaviours, conceptualisation of sexism within medicine, unpacking ‘the hypothetical’, as well as perceptions of prevalence, definition and impact. Chapter Seven also shares participants’ understandings of better alternatives for the future, and beneficial changes to the context of bullying behaviours. The data presented in this chapter is specifically relevant to the research focus of question number one, ‘How do some medical students’ perceive bullying amongst hospital-based doctors?’

7.1. Perceptions of the intergenerational nature of bullying

Most of the participants suggested that, to some degree, the concept of ‘generation’ in medicine impacted on their experiences of being a medical student. Participants suggested that the cycle of abrasive behaviour in the medical profession started long prior to their commencement, and had since become embedded and normalised in the professional culture. As outlined in earlier chapters of this thesis, other studies exploring abrasive behaviours in medicine similarly suggest that medical students perceived that ‘mistreatment’, or in the case of this research, ‘bullying’, were an inevitable part of the training process (Scott, Caldwell, Barnes & Barrett, 2015). This level of congruence is not limited to an Australian context, with studies from , India, Ireland, Canada, United Kingdom and America all reporting, to varying degrees, embeddedness of abrasive behaviours targeted at junior and training doctor (Cheema, Ahmad, Naqvi, Giri & Kallaperumal, 2005; Bairy, Thirumalaikolundusubramanian, Sivagnanam & Saraswathi, 2007; Imran, Jawaid, Haider & Masood, 2010; Cook, Vineet, Rasinski, Curlin & Yoon, 2014). In a sense it has become an expected part of medical training, a as it were. This theory was candidly explained by a number of the participants, reflected in Christine’s comment:

There is a vicious cycle and I’m hoping that it will be changing, but medical students are treated like crap by registrars, so when medical students become registrars they treat students like crap, and then consultants treat registrars like crap so when they become consultants…and it just, it’s really…it’s still sort of happening, and it’s like

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expected…you know your years as a junior doctor are supposed to be hell and then you become qualified and it’s all ok.

A few participants talked about ‘old school’ doctors and behaviours, and Hadley shared, “I think that a lot of old school doctors probably think that that’s how they were treated so they want to enforce the same treatment on the junior staff”. Steve suggested that,

I guess if you’ve been bullied by a consulting doctor when you were a junior doctor, then maybe when you get to be a consultant doctor you may choose to use that power to your own advantage and maybe bully some other people and maybe it’s a vicious cycle in that way.

Looking towards the existing literature and research on this issue, the ‘rite of passage’ nature of bullying or abrasive behaviours appeared rooted in every element of medicine, from the profession itself, the organisations in which physicians practice, the institutions where medical students learn, through to medical specialities or practices. This embedded nature of bullying and harassment in medicine is outlined in Chapter Three. The participants’ awareness of the historically permissive nature of the medical culture is illustrated in the following quotes. Steve noted that, “The problem is that this senior doctor was probably yelled at when they were a junior doctors, by their senior doctor and so on and so forth”. Sally picked up on the idea that medicine has a culture, which capable of change,

The culture of medicine has changed quite a bit from maybe 20-30 years ago and maybe a lot of the senior doctors have brought their values with them and may demand complete respect or authority regardless of who it is. I guess for them that behaviour is acceptable, because that’s what happened to them.

Like a number of the other participants, Amelia noted that bullying could be emulated through either witnessing or experiencing the behaviour, and noted that it is something which is considered typical or customary in medical practice: “I think if they have witnessed it or experienced it (bullying), they think it’s the norm and they perpetuate that”. Abigail noted:

I think there is a culture of hazing… ‘I worked 48 shifts so you should be able to handle 24 hours shift’, and it gets worse the more senior you get, ‘I did it – now it’s your turn’.

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The concept of generation was also explored by a number of the participants in relation to abrasive teaching styles. The idea that abrasive teaching styles were entrenched in a generational cycle was also outlined in earlier chapters of this thesis. A number of the participants’ perceptions on the behaviour were congruent with the results of the recent survey study by Scott et al. where not only was the prevalence of reported teaching by humiliation high, but a strong theme that came through in participant’ responses was that the abrasive behaviour persisted “because it is a traditional practice in the culture of medicine and medical education, and an accepted way of acculturating the young” (Scott et al., 2015, p185e.3). Some participants provided insights into intergenerational legacy and academic humiliation:

This is really unfair. Very mean. I’ve seen comments on websites where doctors are like, ‘this is the way we were taught and this is the way that is effective because if you humiliate them then they’re going to remember something so much more and they’ll never forget. – Rhianna.

I have certainly heard of these kind of (abusive) encounters where really senior doctors who have been practising medicine for a long time, and I think who went through a system where perhaps they were taught in this way, and they think this is the best way to teach. – Amelia

Additionally participants also shared how a sense of generational hierarchy informed them of their place within the professional and organisational hierarchy. Rhianna noted,

Even though we’re on the bottom, I feel that we really do (have some ability to influence others), but definitely not on the same level as … obviously … it’s too obvious to state…but a consultant obviously will.

She suggested, “In the profession specifically, yeah I think when you see the consultants, everyone takes them really seriously, so you just do as well”. Many participants also shared how doctors used generation to minimise difficult working conditions or tasks, and to reprimand the voicing of concerns. Again there was congruence between the medical students’ responses and other studies, which are outlined in Chapter Two. In the quotations below, Abigail and Rhianna illustrated what many of the research participants shared. Abigail noted,

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If you complain to a doctor like, ‘I can’t believe I have to work a night shift then a day shift’, they’re like ‘that’s nothing, in my day I worked 48 hour shifts, you don’t know how good you’ve got it nowadays’. I’d say yeah, it’s a lot better, but it’s still shit.

Generation and practice experience was even used as a reason for poor clinical practices going unchecked. Rhianna noted, “I think it’s unprofessional. I think it’s just… perhaps he’s jaded, perhaps it’s also because he’s at the top of ladder sort of thing and used to being like that”. The perceived intergenerational impact on sexism in medicine was also mentioned by a number of participants. While most of the participants who noted the generational impact on sexism in medicine were female, it was also remarked upon a male medical student. Steve said,

I think these days we know more about workplace bullying and that you know back when they used to think a slap on the arse was a good thing, it was totally fine, and these days … ummm NO!

As with a few of the other participants, Rhianna nominated ‘old fashioned’ views held by male consultants on women in medicine: “Very patriarchal, I wouldn’t say misogynistic or anything, just very much that old fashioned classic cardiologist or surgeon”. Abigail also noted,

The whole older doctor, which is often male, degrading, intimidating students who can’t answer their questions is pretty shit, and the whole thing is pretty confronting.

Some of the participants suggested that they used their gender to their advantage, particularly with older doctors. Christine reported,

I get treated by the doctors differently, depending on how old they are. If they are older males … being a female in a male dominated, or what was a male dominated … you know you can use that to your advantage. I’m not going to deny that I don’t.

Conversely another female medical student suggested that it is male medical students who also used their gender to gain professional advantage. Abigail said,

If a young female flirts with anyone in the hospital, God forbid, but a younger male can flirt the hell out of older female practitioners… like it’s revolting, and they can get away with it because no one sees it as flirting. It’s a young male, but you’ve got these females, these Deans in charge of the medical school, loving this. Twenty-three year old boys

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who are charming and attractive and flirting with them, and then these are the people who win awards.

When it came to future generations of doctors, most participants were generally hopeful that there could be a positive change in the behaviours and ensuing culture of the medical profession. A few of them referenced the influence of changing social norms on the culture of bullying in medicine, such as Rhianna:

Because the new system of doing the UMAT (Undergraduate Medicine and Health Sciences Admission Test) where there’s that section on understanding people, they test your empathy and they do the interview and it’s different than the way they have done interviews in the past, I wonder if that will influence the type of doctors we will become.

Rhianna also said,

I think it’s important to accept that on some level you just have to toughen up. I guess, I find that sometimes that people might mollycoddle people a lot, and we really care for their feelings. You don’t want to be that extreme because people just won’t be able to take criticism, but on the other hand you don’t have to be mean.

Abigail mentioned the idea that the culture of medicine would change, when those currently in positions of power are no longer there:

Culture shift… I am really looking forward to 20 years time where all my colleagues are the bosses. We will be a lot nicer. I hope so…but I think we will be a lot better…It’s already changing, it’s already getting better, definitely.

Others said similar things:

I think it (bullying) definitely starts at medical school and I think hopefully as the older generation start to retire, I hope that it will change, change will gradually occur. – Matilda

I think over time it (bullying behaviours) will just disappear, socially it’s not acceptable, so as the new generations of people come through they know it’s not acceptable to do that sort of thing and so It’ll just go away cos the old ones retire and stop being around. – Steve

Other participants, notably female students, felt that the progressive future of the medical profession was less certain, and that the influence of the current senior cohort of doctors might leave a lasting negative impression. Below are some quotes exemplifying medical students’ responses:

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When I see my male colleagues, you know I wonder what they will be like in ten years’ time and I can often see them morphing in to the same arrogant … senior colleagues that I now work under. – Amelia

I imagine there would still be some amongst my cohort who will be like, ‘I was treated like shit, I’m going to treat you other people like shit’. – Christine

Ashley spoke about the future of medicine with a degree of uncertainty or ambivalence, alluding to the idea of a strong medical culture which was capable of altering intentions and behaviours,

I like to think that I’m never going to be like that, but I wonder if a lot of those people thought that originally too, and then got to that stage and then, ‘oh well, it’s my turn to pick on people’.

Not every participant reported feeling that a change in medical student ‘type’ was positive. For example Steve noted that:

Some doctors say that the standards have slipped a little bit from what they used to be … There’s certainly a lot of medical students coming through that can talk to people better than most of the older doctors can. But they might not necessarily be as technically competent or academically, you know, as sound as the older doctors.

A number of medical students talked about the need for senior doctors to remember that they were once students themselves. It might be that participant’s hoped that in remembering the past, senior doctors would be able to empathise better with current student cohorts. This response also dovetailed with a concept found in Chapter Eight, where participants reported that one of the impacts of senior doctor’s abrasive behaviours was the dehumanisation and devaluation of the students. Below are quotations from four of the medical students on this particular issue. Abigail noted: “Senior doctors need to be reminded that they were students once, but the thing is a lot of senior doctors were treated like that when they were students”. Central to many of the students’ beliefs on the way older doctors treat junior doctors and medical students was the concept of . Lily said,

Remembering where you came from is really important because it humbles you. I feel like you can’t be a doctor and not have humility, I think that’s a recipe for disaster otherwise.

Sally also suggested,

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Doctors seem to forget that they were once medical students and don’t really understand we end up wasting a lot of time that could otherwise be productive, just because they are completely ignoring you.

And Lily noted, “There are so many good mentors that always remember times when they were medical students or junior doctors… and you know that they get it!”. The ability for senior doctors to reflect on how it felt to be a medical student or a junior doctor just starting out in the profession was considered a flaw not uncommon to many specialist consultants. As Amelia shared, “I mean, it’s quite dismissive of that students concerns and insecurities and fails to recognise that they were at this stage once and they are learning”.

7.2. Conceptualisations of the causes of bullying behaviours

This section of the chapter explores the participants’ conceptualisation of the perceived cause or contribution to bullying amongst hospital-based doctors. Specifically, their perceptions of individual contributions, professional and organisational culture, and the broader community are described. The majority of the participants espoused the belief that there was often a significant individual contribution to an incident of bullying. This is in line with other comparable studies (Rees & Monrouxe, 2011 Snell & Gan, 2014), which were outlined in Chapter Three. Many of the participants suggested that both the perpetrator and the victim contribute to an incident becoming abrasive or hostile. To illustrate, Hadley said, “Insecurities are usually at the root of it (bullying)”. Lily shared the belief that medicine attracted a high proportion of individuals who might be considered unpleasant in character or temperament, “Weirdly maybe some people just enjoy making people feel crap about themselves”. Steve appeared to agree with Lily’s insight, “There’s a lot of pricks in medicine to be perfectly honest, that don’t have interpersonal skills to save themselves”. Teddy spoke about the abuse of power as a key motivator to bullying, as well as a conflict driven by individual personality traits, “I don’t know… Power trip. Personality clashes”. Steve noted a lack of empathy as another motivator:

Not everyone that goes into medicine is that good at dealing with their own…they can deal with a patient, empathise and all that sort of thing but dealing with their own frustrations and issues can be difficult.

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Christine thought bullying might have something to do with testing personalities for resilience, “I think some of them do it to sort of test you almost, like test your willpower, and ring of fire kind of thing…like you pass the test I won’t do that anymore”. Perpetrators were not the only individuals to be perceived as contributing to the bullying phenomenon. The majority of participants suggested that the targets or victims of the abrasive behaviours contributed to its occurrence, which corresponds with other studies outlined in earlier chapters. Different perspectives of this issue were captured in these responses:

He’s (the target of bullying) also managed to bring it on himself a little bit...if he was slightly more likeable, I’m sure it would not happen. But he makes no attempt at being more likeable… – Dr Nick Riviera

Chuck shared the idea that, as a medical student he was worried that it was always possible that they may have made a mistake, that their performance or knowledge was somehow up to scratch. The concept of fear of ‘mistakes’ made by the medical students, was raised by most of the participants, “From the junior person’s point of view, ‘what if there’s something wrong with me…’ there’s always that thought”. Many participants, including Oliver, did the target of bullying to some degree:

I think the medical student was quite sensitive to criticism, but at the same time the consultant was definitely condescending. Sort of an intent to academically humiliate.

However, other participants like Lily, suggested that medical students were most likely to blame themselves first for bullying they experienced: “It’s kind of like that whole blame the victim, they blame themselves or something they could have changed or avoided the circumstances”. Abigail was the only student who mentioned the sexuality of those who are targeted, as a reason for being bullied, or harassed: “Anyone who identifies as LGBIQ as a medical student has it real tough, like real tough”. Abigail also mentioned that medical students and doctors of Asian descent were also targeted for bullying by both other doctors and patients. Some of the participants felt that abrasive behaviours, such as the one outlined in the hypothetical case scenario (see section 7.4), or in incidents they had experienced, could be justified as just part of the training regime. “If it was really, really simple, then

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I would start to question why the junior doctor had not been answering. If the junior doctor had done something so ridiculously stupid that could have actually put the patient in harm”. Dr Riviera continued by wondering aloud, “What initiated the situation”? A few of the participants suggested that abrasive bullying behaviours by senior doctors were often just part of the training, Rhianna said, “They just want you to be better doctors”. Chuck also noted this: “The senior doctor might just be trying to teach or trying to make them learn a lesson or something”. A couple of the participants picked up on the changing broader social context that doctors now operate in, and how that might impact on their behaviours:

I don’t think so much amongst the new doctors that are coming out, but the older generations are very much ego driven and probably went to medical school in the days where doctors were worshipped as Gods, so they consider themselves to be very important people. – Matilda

It has been suggested that there is a growing discontent within medicine that doctors are increasingly devalued by society and usurped by easily accessible information, a discontent and disconnect between how doctors value their own profession versus how others are increasingly seeing it, which may contribute to bullying amongst doctors (Ivory, 2015). Dr Nick Riviera said, “Oh I’m going to see the doctor, but I’ll Wikipedia it or Google it first so I know what is going on”. And Christine noted:

Think about how medicine has changed over the years, it’s gone from a very …patient is like ‘yes doctor, I will do whatever you say doctor’, and doctors were like hot shit, and mostly male, and now patients have Google and they get second opinions and there are more females and you know medicine has changed, society has changed.

A number of medical students suggested that perhaps the bullying behaviours are just what a hierarchy looks like.

I guess experiencing hierarchy…at the start I thought, ‘okay that’s how it happens, that’s how medicine work’s, but then as I have been part of different teams I have realised that that is not necessarily how it works, it’s how the people in the team choose to work. – Mathalda

As new practitioners, sometimes straight from high school, medical students differentiated between a functioning organisational or professional hierarchy and abrasive, bullying behaviour. To illustrate:

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Could be bullying or, I don’t know, it’s kind of just the hierarchy. – Ashley

You’ve got people who are of very similar ages in charge of each other, who could have gone to med school together, could have been friends, but you know one person is kind of bossing the other person around, so it’s hard. – Abigail

Most of the participants referred to the idea that because bullying is an expected part of the hospital workplace and medical professional culture, targets and witnesses were unlikely to formally complain about it, arguably contributing to the perpetuation the abrasive behaviours (Salin, 2003). Some of the different participant insights on the issue are illustrated in these quotes. Ashley said,

The sad thing is it’s acceptable in this environment. Um, it shouldn’t be acceptable, and I don’t think in any scenario it would be acceptable, but unfortunately in the hospital or in health setting, it’s just the way it is.

Sally noted: “It might be that’s the expected workplace culture and sort of everyone has to go through it and deal with it”. And Amelia shared, “I think mainly if it’s the norm and this is the way it’s always been done, then the senior doctor’s not going to have any qualms about bullying a junior doctors”. There was such a sense of overwhelming inevitability of encountering abrasive, bullying behaviours from senior doctors. The majority of the participant responses, included words such as expected, acceptable, normal, recognised and tolerated, when it came to talking about these behaviours:

I don’t know, because it is so in-ground in the culture, like people higher up will be like ‘what’s the point in changing it ‘I’m fine’. Do you know what I mean though? I mean how many people have to commit suicide? – Ashley

I really had no idea how the hospital system worked, how people are expected to behave in all members of the team…So I just kind of had the general feel of what it’s like in the general community and how you’re supposed to act with people, but then of course you’re in a profession, straight out of high school, so I’ve never been in a profession before. – Mathalda

Steve shared that, “I’ve been yelled at, I tolerate it, we all do”. Ashley noted,

It’s kind of like an induction, but it’s a terrible sort of induction, and it stretches out for a long period of time, yeah, I think maybe it would be like ‘toughening us up’, or whatever. But it’s a terrible way to do it.

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Furthermore, a few participants suggested that hospital management interactions with professionally powerful doctors tacitly permit or enable their behaviours, even if the behaviours are occasionally less than optimal or are considered unprofessional. Christine noted:

The surgeon that would like throw scalpels around the operating room and because they’re like this crazy super awesome neurosurgeon, they’re permitted to continue to do that because they sort of are somewhat irreplaceable. I wonder if they know that and I wonder if they know that they can behave like that because their job is secure?

A number of participants questioned whether there were aspects of the profession itself, which contribute to bullying. Professional dimensions of abrasive behaviours reported by participants ranged from types of tasks performed, time constraints, workload, level of expectation, high levels, professional history, competitive nature, and training methods. These perceptions were mostly congruent with reports by workplace bullying experts outlined in Chapter Three. Medical students from the Rees and Monrouxe (2011) study also nominated workplace and task time pressures, as well as the competitive nature of medicine as contributing to abusive behaviours amongst doctors. The quotes below outline the different perspectives of the participants on aspects of medicine, which contribute to bullying. Rhianna shared, “The fact that it’s a high pressure environment and that there are patients whose lives are sometimes on the line”. Lily noted, “In theatre it’s its own little world, I feel like whoever is doing the procedure if they are snappy I kind of take it lightly, I understand it’s high pressure”. And Steve believed, “Time … taking too long to do things is certainly something that generates a lot of stress. There’s not enough hours in the day for the things we need to do for people”. High levels of stress, which reduced the capacity for doctors to control their emotions, was nominated by Sally as a contributing factor to bullying behaviours. Although she did not elaborate on which emotions were difficult to contain, anger is one that comes to mind,

I think it is a situation of high stress and it is very hard for people to maintain a level of control, is probably the right word and so it is very easy to let your emotions get the better of you. Not just stress but, I guess urgency as well, there are so many things to be done and it never ends.

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Abigail also identified the pressured nature of the environment that led to a loss of manners:

A lot of it is very high pressure, we have very quick interactions, a lot if urgency as well and so sometimes manners are easy to forget because you know, you’ve got a patient and you need a MET call right then, it’s hard.

While the quotes above focused on the time and task pressures of medicine, below Steve mentioned that the career of medicine could be very competitive. Competition for training spots was recently recognised by the Australian Medical Association, who reported that medical school graduate numbers have almost doubled since 2002 (https://ama.com.au/media/redistribution-medical-school-places-not-sole- solution, accessed 19/07/17). With a new rural medical school being proposed to span the New South Wales and Victorian border region, the competition doesn’t look likely to abate (Hare, 2017). In this context, Steve suggested that,

Medicine is becoming a very cut-throat environment these days, so if you don’t step on people, you’ll never get ahead sort of thing. For example ENT surgery, to get into that there are only ten spots per year. Two in each State and that’s it, and there are hundreds of people who would want to do that. General surgery, there’s lots of spots but there’s still thousands of people who want to do that.

A couple of the participants referenced the idea that expanding management and professional expectations, and increasing workloads for hospital-based doctors may contribute to bullying behaviours. For example, Steve noted that, “These days I think there is a hell of a lot more stress than there used to be because one doctor might have 40 patients they’re looking after”. Striking in its absence was any discussion on a perception of collective contribution to bullying behaviours. While participants noted aspects of the medical profession such as time constraints, and task pressures, any collective contribution on a broader scale, such as professional expectations, community expectations, or organisational and professional dynamics of power were absent from the medical students’ discussions. The only reference to the concept of a collective contribution was actually still based on a particularly individualistic concept of personality influence. Dr Nick Riviera commented that:

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we could all say we are narcissistic, so we’re all trying to get something out of…it’s all about me…it usually means that we don’t tend to stick up for somebody else, unless it actually will impact on them.

As outlined in section 7.1, on exploring intergenerational influence, most of the participants felt that the abrasive behaviours exhibited currently by doctors were often a result of an historical or generational cycle of abrasive or bullying behaviours by doctors past. Mathalda said, “Having that done to you when you were younger and then finally getting to the point where you can do that to other people, I think is a rite of passage for a lot of people”. One participant also reported his belief that the type of individual who was historically encouraged to go into medicine was very different to the individuals entering the medical schools of today. That contention is certainly born out in the literature on medical school admissions, which documents changes over time in both in Australia, and in the in diversity of medical school applicants and graduates. These changes relate specifically to inclusion of ethnic minority, international students and gender (Health Workforce Australia, 2012; Monroe. Quinn, Samuelson, Dunleavy & Dowd, 2013). Steve noticed this increasing diversity:

I think there is a broad range of people coming in. They’re not all super A type, they’re not all switched on and not all as conscientious and that sort of thing, so I think there are more people now that could annoy the upper A type doctors that are still practising.

A few participants suggested that certain medical specialities contributed more to the phenomenon of bullying. Abigail, for example, noted, “Surgeons fit the that they are … often a lot shorter (brusquer)”. Most of the participants conceptualised that the cause of bullying as multifaceted. One participant had prepared a diagram (Figure 7.1) in order to illustrate the influences that she felt contributed to bullying amongst doctors.

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Figure 7.1 Participant diagram on ‘medical workplace bullying’

Abigail spoke to her diagram, and explained that she perceived gender, hierarchy and perceived pressure to perform well as the key reasons for ‘medical workplace bullying’. She elaborated that the gender issue was ‘a whole big issue”, and that females were not just discriminated against, but rather, male medical students were favoured by those doctors on clinical rotations. In Abigail’s words,

there are these boys who are really, really good, and so they kind of get mollycoddled, like some of the surgeons are like ‘come here’, they’ve got attitude, they help them out if they see they have potential. Huge favouritism happens. It’s usually the outgoing, charming attractive young lads.

She also said,

God forbid but young males with older female practitioners…like its revolting, and they get away with it because no one sees it as flirting…but you’ve got these females who are in charge of medical school, loving this, 23 years old boys who are charming and attractive and flirting with them, and these are the people who win awards, these are the people who get favouritism.

With the notion of hierarchy, Abigail felt that its influence depended on the hospital you were in, and while she nominated that bullying behaviours can be caused by “a lot of hierarchy”, she didn’t clarify what she meant by that term. Abigail did

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however, share a time where she recently worked at a research institute that did not have a strong sense of hierarchy, and she said that everyone was “treated totally equally”, so perhaps for Abigail her notion of a hospital hierarchy was hallmarked by inequity. Abigail concluded her discussion on comparing other workplaces with the hospital by saying “you really become aware of how shit you’re treated in the hospital”. With the concept of perceived pressure to perform, Abigail specified both academic performance and physical stamina required to become a doctor. She shared her belief that having to work, and survive, long physically punishing hours is considered a matter of for qualified doctors “there’s a lot of pride, it’s a very ingrained thing”. Many of the participants focused on the particularities of the medical profession, the ways in which being a doctor or a medical student is unique, in the context of workplace bullying. There was a sense in the participants’ responses that these perceptions of particularities not just contributed to the bullying behaviours, but also were considered valid reasons for the behaviour. This perception is also captured in the responses from surgeons on the 2015 RACS report with one of the surgeons suggesting,

there is a need to test for and eliminate weak personality types. You need personalities you can rely on when things get really serious and you don’t want emotional breakdown under critical situations. Selection and training must be robust and real life based. It’s selection of the fittest (RACS, 2015b, p. 30).

There was the time pressure, and the life-and-death tasks of a medical student and doctors, as captured by Abigail, “if it’s an acute situation, like giving out medication that can kill them, it’s bad, and you kind of understand that people are going to yell”. There were moments within the interviews where participants alluded to the idea that the unique core characteristics of medicine is why bullying might initially occur, and why it might be difficult for those outside medicine to fully understand the contributing pressures of being a doctor. Steve noted:

I think it’s hard, it’s hard for people outside of doctors to understand why it happens…until you’re in that really super super stressful environment where people die from the wrong decision, you never know how you’re going to behave or react to it.

The notion of medical ‘exclusivity’ as an antecedent factor, one that may also foster a culture of tolerance, thereby perpetuating the bullying behaviours, has not to date, been unpacked in any other studies.

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7.3. Conceptualisations of sexism within medicine

As with the insights of perceived intergenerational impact on sexism (section 7.1), the majority of the participants who mentioned sexism in medicine were female. There were a number of theories raised by participants, as to why sexism might still have existed within medicine. The notion of intergenerational influence was reported earlier, however many female participants also mentioned the influence of media coverage on sexism, harassment and discrimination in medicine. Matilda noted, for example:

In stuff I’ve read in the media about women, female doctors who have reported sexual harassment, there’s quite a few examples where their careers have been ruined. They haven’t got in public hospitals again.

As mentioned previously in Chapter Three, a focus during 2015-2016 from Australian media outlets on bullying and harassment of medical juniors by senior doctors, meant that the issue of bullying, and sexism in medicine was given high public visibility. Furthermore, during this period, much of the media coverage highlighted the unfavourable outcomes that had occurred for those individual targets of bullying or harassment that had spoken out against the behaviour, or the medical culture that appears to condone it. Mathalda noted that in light of recent media attention on harassment in surgery “everyone was sent a very stern email in the past couple of weeks, not to mention ANYTHING about gender at all”. Following the establishment of the RACS EAG in order to investigate bullying and sexual harassment in surgery, a number of actions and strategies had been put forward in order to combat the issue. However, in 2008, it was published nationally that the RACS had sought advice from a lawyer regarding the matter of bullying and sexual harassment within the surgical speciality. It had been warned that it “cannot be lightly ignored” (Medew, 2015b) yet it still chose to do nothing, and has perhaps contributed to many of the participants still being sceptical of the possibility of meaningful and sustained change within the profession. Amelia and Abigail noted the ongoing sexism:

I think it is changing (culture of sexism in medicine) and I think it requires women as well to stand up to them and call it out, and I think the difference is that a lot of my male peers are quite impressionable still, so you can cut them down and pull them up, whereas I wouldn’t be able to do that to a senior doctor, I’d let it slide… – Amelia

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and females wanting to be surgeons…God forbid they want to train to be a surgeon, it’s really hard for them. It’s a macho club. – Abigail

7.4. The hypothetical

As outlined in Chapter Five, participants were invited to respond to a hypothetical scenario. This scenario included behaviours congruent with many objective ‘operationalised’ definitions found in guidelines for Victorian hospitals, medical professional bodies, as well as legal and regulatory documents. The hypothetical scenario, see Figure 7.2, included the criteria most often found in academic definitions of workplace bullying, noticeably frequency, and duration, power imbalance, as well as negative outcomes defined objectively by others and the target of the bullying (Einarsen, Hoel, Zapf & Cooper, 2011).

‘A senior doctor shouts at a junior doctor for not answering their questions quickly enough. They do it in front of other staff and patients. This happens on a fairly regular basis, and the junior doctor is starting to question their own capacity to one day be a competent doctor. At times the junior doctor feels humiliated, and where possible, they have started avoiding interactions with the senior doctor’.

Figure 7.2. Hypothetical case scenario

Participants were asked a series of questions related to the hypothetical. Much of the participants’ discussions surrounding the hypothetical were centred on their conceptualisations of prevalence and definition of bullying amongst doctors. The hypothetical also created a springboard for participants to share their own experiences of bullying. Most of the participants felt that, while the majority of interactions amongst doctors working and training in hospitals were characterised as being civil and supportive, hostile or abrasive behaviours amongst doctors were not uncommon. The participants’ perceptions of prevalence were fairly consistent with both the Australian and international studies, as explored in Chapters Two and Three. These studies reported a considerable level of bullying or harassment had either been witnessed or

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experienced directly by many medical students and trainee doctors. Although all the medical students interviewed said that they have either witnessed or been targeted by abrasive or harassing behaviours, irrespective of whether they then labelled those behaviours as bullying, it could be argued that the students volunteered for the study based on pre-existing experience or interest. Conversely, it might also be considered that workplace bullying is an underreported phenomenon, so the fact that all participants had witnessed or experienced abrasive behaviours might indeed reflect a more accurate account of prevalence. However, it is interesting to note that while there were definite parallels between participant perception of prevalence and broader conceptualisations of prevalence, participant perception of definition varied from other studies definitions of bullying behaviours. Many of the criteria given by participants as essential measures for labelling behaviours as bullying, were different to criteria set out in policy, academic, legal, or regulatory definitions. Participants felt that the context of abrasive behaviour (public vs. private), intention, and apology (or lack thereof) were important criteria in defining behaviours as bullying. Furthermore, a few students suggested that while they had witnessed or experienced behaviours that were not optimal or ‘professional’ they were not sure that they constituted bullying. While the medical students interviewed were keen to convey that hostile or abrasive behaviours occurred on a regular basis, they appeared to be less confident in labelling certain actions as ‘bullying’ behaviours. On the following pages are some of the participant conceptualisations of both prevalence and definition of bullying. These conceptualisations on prevalence and definition were part of the medical student responses to the hypothetical case scenario.

7.5. Conceptualisations of prevalence of bullying

Teddy suggested abrasive, bullying behaviours were, “just a very common occurrence”. Oliver said,

You see it quite often, you see academic humiliation in a way where a consultant questions, repeatedly really, one person, until they can’t answer anymore, that sort of happens, so I guess you get used to it, and sort of laugh it off in a way.

Steve commented that not only does bullying happen often, but its rates of occurrence were not going to change anytime soon: “My thoughts are … yes it happens

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on a pretty regular basis, I mean, I know it happens and I don’t think anything is ever going to change that in the near future”. Most of the participants used words such as “common”, “regular”, “a lot” and “all the time” to describe prevalence of bullying behaviours. As Ashley suggested, “it’s just the way it is”. In responding to the issue of prevalence, there was a sense from medical students that the occurrence of bullying behaviours amongst doctors was so embedded in their everyday clinical experience that they had become almost emotionally unmoved by it, or heedless to its existence. To illustrate, Steve said, “I think medical students know it happens, everyone in medicine knows it happens”, and Ashley noted “Well I personally have experienced something like this scenario, and seen a lot of it. …It’s not acceptable, but it happens all the time”. Abigail reported that, “There are lots of occasions of consultants ripping into junior doctors. It’s quite common”.

7.6. Definition: What is bullying? Including individual, organisational, professional, and broader influences

One participant explained that, through a process of rigid hierarchies and undermining, the medical and organisational cultures became so deeply rooted in a doctor’s character, that they are unable to confidently label behaviours or interactions as ‘bullying’.

We’re not very confident, especially given the fact that the people who are senior to you will be senior to you for the next 20, 30, 40 years quite potentially. You don’t want to step on any toes. Sometimes we just don’t feel confident enough in ourselves that what we have witnessed is something that should not be happening. A lot of things become acceptable, even though initially starting off we would have been outraged. You become embedded in the culture even if you do not necessarily agree with the things that are going on. – Abigail

Criteria that participants included in order to label an action or incident bullying, were wide ranging, but most often included the notion of public humiliation and intention to hurt or embarrass. It was interesting to note that an Australian study which was discussed in the earlier chapters, explored definitions of workplace bullying and also found that the notion of ‘intent’ was significant for people looking to label behaviours as bullying (Saunders, Huynh & Goodman-Delahunty, 2007). That study reported that 21.4% of the respondents had nominated ‘intent’ as core to a behaviour

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being considered ‘bullying’, however intention to cause detriment was not considered essential in most objective operational definitions of workplace bullying which are often found in policies, codes, regulations or legal Acts. The disconnect between objective (operational) and subjective (personal, or individual) definitions of workplace bullying will be considered further in Chapter Nine. On public humiliation, Rhianna said, “If you’re doing it in front of other staff and it’s just shouting for not answering questions quickly enough, I think that’s bullying”. Amelia said, “I think yelling at the student in front of peers is never appropriate”. Like many of the participants, Lily used the word “humiliated”. ‘Embarrassed’ was another word commonly used by the medical students. Lily said, “And that person feels humiliated, and it’s almost like a display, they’re putting them on display”. Oliver recounted a specific experience of witnessing humiliation:

It was in front of a group of medical students as well. The medical student’s colleagues, so that added to the embarrassment of her and then there was further embarrassment that she was reduced to tears as well. It was a pretty nasty situation.

The element of public humiliation in bullying was also picked up in the RACS, EAG research report, with some surgeons, and trainee surgeons noting that “these harassments and bullying occur in public, in front of patients, other health staff” (RACS, 2015a, p. 28). Intention to bully was also found to be an important factor for participants. This was mirrored in the results from the Rees and Monrouxe study on medical students’ understandings of ‘abuse’ (Rees & Monrouxe, 2011). On intention and bullying some of the participants shared these insights:

Intention to humiliate, intention to make them feel bad about themselves. Especially if it’s in front of the team because that really does bring out the humiliation into it – Mathalda

It’s when someone’s unpleasant or sort of ignoring intentionally, or does something intentionally, almost goes out of their way not to help you achieve your goals. – Chuck

Chuck continued,

The person doing the bullying is probably not thinking that they are bullying but more thinking that, “I’m in a rush, I need to get this done, this person clearly knows less than me’, which is true.

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However, not all participants felt that intent was important in defining behaviour as bullying. Steve said, “I mean you don’t need to be intentionally bullying someone it could be unintentional”. When exploring the hypothetical given to interviewees, many participants suggested that what defined the situation, as ‘bullying’ was twofold, firstly that the shouting is done in public, and then that there is no apology. Many participants then used the hypothetical to explore similar situations that they had experienced themselves, and how the context or apologies by the perpetrator of the hostile actions has helped them define or label the behaviours:

I think firstly it is in front of everyone. Secondly, there is no debrief afterwards, saying sorry I shouted at you, but this was important and that’s why I had to do it. No justification. Even if there was (an intention beyond embarrassing them) it wasn’t clearly explained. Whereas, if it was sort of A. private and B. explained or justified, then maybe it wouldn’t be counted as bullying. – Abigail

There was a bunch of people there cos it was a ward round, so that was quite embarrassing for the Intern. Everyone was standing going ‘yep, this Consultant does this a lot. – Steve

When talking about how a senior doctor gave feedback to a medical student, Ashley said,

I think the way that she went about it was completely inappropriate…it was just done totally wrong an in a way to make me look and feel stupid basically. So, I don’t think there was any, um, teaching component of it. It was really just bullying.

And Lily reflected, “I feel like it (abrasive behaviour) is OK because they’ve apologised and they’ve admitted or acknowledged that what they said or how they said it wasn’t appropriate”. Some of the participants indicated that the nature of the medical interaction would influence whether or not they would define it as bullying. Responses indicated that in the case of medical emergencies, abrasive behaviours, even bullying behaviours would be labelled as something else. This belief corresponded with the feeling from participants that sometimes the target of bullying behaviours could contribute to the incident, and that the nature, or some tasks in practicing medicine might provide caveats for abrasive, bullying behaviours. For example, Sally said, “I still do not think it is acceptable, but I would be sort of more hesitant to label it as bullying if it was in an

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acute situation”, and Rhianna said, “I think there is room to be like that because I mean it is patients’ lives at stake”. While the vast majority of participants did not say a pattern of behaviour, or repetition must be present in order for incidents to be labelled as bullying, many of the participants suggested that if an abrasive behaviour was repeated then it could likely be defined as ‘bullying’. To illustrate, Lily said, “It becomes a bit of a problem if it’s something that’s recurring”, and Oliver noted, “I guess bullying is a long term harassment thing, and if this senior doctor is doing this repeatedly to that junior doctor, I would say that is workplace bullying”. Terms such as “regularity”, “often”, “recurring”, and “repeated” were used by participants to indicate the idea of bullying being something that happened more than once, Mathalda suggested, “If it happens on a regular basis then yes it is workplace bullying”. Dr Nick Riviera highlighted this also in saying, “Workplace bullying is more along the lines of systematic targeted comments or actions against another doctor, which has no basis or has a trivial basis”. Sally commented, “I feel like bullying would be sort of singling someone out repeatedly”. A couple of the participants suggested that one of the criterion needed to define an incident as bullying is if the target or victim reported that it had a negative impact:

I mean society’s opinion of norms change a lot…The junior doctor feels humiliated and I’m pretty sure that’s one of the definitions of bullying in the workplace. – Steve

Most of the medical students alluded to the presence of power disparity in abrasive or bullying interactions, even if they do not have the language to describe the contextual processes or structures of that power inequity. As referenced in Chapters One to Four, power inequality between the target and the perpetrator of bullying is also considered a core factor in much research on workplace bullying. Interestingly, interpretations of why power disparity plays such a significant role appears to vary widely from study to study. For example, a cross-sectional survey of junior doctors bullied in Pakistan raised the possibility that the Pakistani culture of revering authority figures such as teachers or elders may play a significant role in junior doctors being unlikely to report bullying, or stop it should they witness or experience the abuse (Imran et al., 2010). An Australian study suggested that younger doctors may be awarded “lower status” within hospitals and are “less skilled or experienced in aggression risk minimisation and de-escalation,

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including where the perpetrators are more senior medical personnel”, which presumably increases their vulnerability to bullying (Hills. Joyce and Humphreys, 2011, p. 256). The recent Expert Advisory Group to the Royal Australasian College of Surgeons looking at the issue of power and bullying systemically indicated that “abuse of power and authority is a significant cultural issue” (RACS, 2015a, p. 8). The role of power abuse and oppression in bullying amongst hospital-based doctors will be considered further in Chapter Nine. However, perhaps Lily, articulated this power disparity most comprehensively when she suggested that,

The fact that it’s (bullying) between a senior and a junior as well, while that hierarchy is there in terms of power, that hierarchy is also there in terms of knowledge and experience, and if you’re in a position of power you don’t abuse that, even if you are teaching them everything you know, it doesn’t give you the right to belittle them. I’d definitely call that workplace bullying.

Much of the participants’ discussion on power disparity centred on its role in impeding junior doctors and medical students from reporting bullying, this is discussed in further detail in section 7.7. A few participants felt that bullying may well be something more benign. Their responses raised questions as to whether an overuse or popularisation of the term diminished its perceived power, or people’s willingness to apply it to hostile or abrasive behaviours. One participant wasn’t convinced that the abrasive behaviours he saw in clinical placements could be labelled as bullying at all, and raised the question over whether bullying even existed in medicine. Hadley further suggested, “Bullying is, you know a very common term at the moment and bullying is occurring everywhere…” Chuck reported that he felt bullying was, “probably more of a misunderstanding and a sort of ‘one person’s perceptions or opinions of what’s happening is different to another”. While the RACS Expert Advisory Group defined sexual harassment and discrimination in medicine as phenomena separate to bullying, one of the medical students believed that sexual harassment and discrimination should also be considered as a form of bullying. There was definitely overlap in some of the participant descriptions of bullying behaviours and sexual discrimination and harassment experienced. Abigail noted the impact on women:

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I’d probably say that women are still actively discouraged from certain medical pathways, and experience inappropriate remarks about their looks, or clothing and are restricted or made to do certain tasks solely because of their gender, and this is all bullying, and women should report this behaviour.

7.7. Beliefs on the impact of bullying

This section explores how research participants conceptualise the impact, or the effects that the bullying might have. This differs from the actual reported impacts that participants experience first-hand. The participants’ descriptions of experienced impact are recounted in Chapter Eight. There were some differences noted between what a medical student perceived as the impact of bullying, and what they actually experienced. Most participants had strong beliefs about the potential negative impact of reporting bullying to those with authority greater than themselves. As noted in earlier chapters, this is consistent with other research into bullying amongst doctors, and in healthcare generally. The submission into the Senate inquiry into bullying and harassment made by the Australian Medical Students Association (AMSA) acknowledged some of the many obstacles for medical students reporting bullying, stating “fear of receiving negative feedback or poor marks in assessments from the perpetrator, and fear of gaining a bad reputation which could affect the victim’s long term career prospects”, amongst others (AMSA, 2016, p. 4). Furthermore, many of the medical students perceived the individual impact of bullying to be unfavourable for the target. A few of the participants imagined that bullying amongst doctors might also be detrimental to patients. Interestingly, a number of the participants also floated the possibility that bullying could have a positive impact on some of the targets. A couple of the students perceived that the impact of abrasive incidents was relatively minor; something, which one should just ‘get over’. Although participants touched on the perceived impact of sexism in surgery, such as the sense that it was a ‘boys club’, which was hostile to female doctors, no participants shared their understandings of impact on a broader, collective scale. Perceptions of impact on hospitals, profession, specialties, or wider community were largely not mentioned by participants.

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Participants reported that fear of consequence or retribution played a significant part in not reporting bullying behaviours. This fear of consequence was mirrored in a significant portion of the narratives shared in the RACS commissioned study on bullying and harassment in surgery, as two of their respondents shared, “I complete this questionnaire with a large degree of fear and trepidation”, and nothing is anonymous in medicine…even filling in this questionnaire is extremely uncomfortable” (RACS, 2015b, p. 32). These medical students believed around the impact of reporting bullying to be as follows. Sally said, “I guess fear of retribution, not only professionally but personally and the fear that if you report it, it could get worse”. Dr Nick Riviera suggested that if a medical student intervened in a case were someone else was bullied, they would risk becoming a target themselves, “He’s managed to annoy an entire year and an entire hospital, and if I stick my neck out I’m going to get locked in it, and it’s going to happen to me as well”. A few medical students used the phrases “ruffling feathers” and “rocking the boat” in relation to not reporting bullying, maintaining status-quo and fitting in with the dominant culture of medicine, Oliver said,

Scared that it is going to affect my future prospects because they’re much more senior, they have much more communication connections, a lot more experience. Certainly, I don’t want to ruffle feathers, rock the boat!

Amelia said that she wouldn’t report bullying because “I think predominantly the fear of antagonising that person or getting a reputation for yourself as somebody who complains”. And similarly Rhianna said:

I don’t think I would report anything like that. I don’t think…it’s too hard to, and again the whole career thing, you don’t want to ruin your career before it’s started. You don’t want to make a fuss.

The words that medical students predominantly used to describe their perception of formally reporting bullying were powerful, they included fear, consequences, reputation, scared, and retribution. There was no trust evident in the system to manage or process their complaints effectively or confidentially. For example, Teddy noted, “I think you’re scared of the impact on your career and ultimately you’re scared of the future of the relationship that you’re going to have with that colleague by reporting it”.

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Matilda noted with formally report bullying, “I guess there is a fear that you will be considered weak or ummm…not up to the job”. And Lily noted:

Ohh the fear of those consequences, to their career, to their reputation. Ummm, how are they going to go to work the next day, knowing that everyone is going to know that this happened to them, or that they’ve reported it.

As previously mentioned, a number of the participants demonstrated a lack of awareness about their hospital’s policies on bullying behaviours amongst staff. Furthermore there was a reported lack of knowledge on the organisations Human Resources Department, or even whom the medical students might lodge a formal complaint with. To illustrate, Matilda observed, “Apparently there’s hospital HR departments, but I wouldn’t really have known that until recently when I read about various things in the media”. And Steve said,

I mean HR is always good at keeping things quiet but there were a few incidents that I heard about last year where there were some repercussions for the perpetrator and it was known who had reported them. It’s kind of…people would be wary of them, ‘oh that’s the tattletale’ that sort of thing.

Many of the participants did not appear to trust the process or the people in charge of an investigation. On reporting an abrasive behaviour witnessed, Mathalda shared, “I don’t think I would feel like I should be the person reporting that I wouldn’t know who to report to actually”. Not only did some participants comment on their own lack of knowledge of who to report to, and the lack of trust in existing known processes, a couple of the medical students reported that they felt that there was actually no one immediately available to discuss their concerns with, as noted by Matilda:

at the time we didn’t have a clinical Dean because he had resigned and the uni had not replaced him to save money and so… there was literally no one to talk to about these issues. A lot of us in that cohort that year that were at this placement had a really difficult year because we were completely unsupported.

For those medical students who had experienced or witnessed bullying behaviours, the inevitability and scale of the bullying phenomenon seemed to thwart the very idea of formally reporting it. Ashley reflected that, “There were lots of times where…you just don’t report it…just because that’s how it is”. Steve also reflected on his response:

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I think these days young doctors, or most young doctors and medical students coming through are probably more likely to just go, yep, this is what happens and just ignore it sort of thing, like it’s water off a duck’s back, I would probably let it slide at because it’s … at the moment there is nothing personally I can do about it.

Many of participants perceived a connection between the power disparity of the perpetrator of workplace bullying and the target, and the absence of formal reporting. Sometimes that was because the person in a position of perceived ultimate power, and the perpetrator were one and the same. Teddy shared her experience:

No one did anything, and again, he was like the most senior, and as I said before, he wasn’t just a senior doctor, like a consultant, he was the Head of Medicine in the hospital. So I assume his position, because of his position, everyone just… no one said anything.

Matilda also commented,

Well, often the people that you have to report to are in fact the person who is perpetrating the behaviour in the first place. I think it’s pretty hard when the people that may be perpetrating the behaviour are responsible to some degree for your career progression, or to provide a favourable reference, could influence your career progression.

And Lily highlighted the power differential further:

Ultimately it’s your consultant that signs you off at the end of the day, and if your consultant is the perpetrator then you’re in trouble. It’s because of that power differential. This person has your career in their hands for that period of time, you don’t want to bite the hand that feeds you.

For other medical students it was the fear of negative career retribution, or the learned knowledge that as medical students the bullying behaviours were expected, and to be endured as part of the medical training process. Ashley reported:

as medical students we’re just supposed to cop it on the chin, we’re expected to just, you know, just accept it basically.

Chuck said “It is often the senior ones doing it to the younger ones and the younger ones references obviously depend on the senior ones, that’s the obvious reasons”. And Ashley noted that,

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if we were to say anything back that was in any way to defend ourselves, or if we were to step in for another person getting, you know, bullied, we would immediately be called unprofessional, or have complaints put against us.

Several participants mentioned that they felt reporting a witnessed incidence of bullying or abrasive behaviour was not their responsibility, often citing that they wouldn’t want to report something in case the target did not want it to be formally reported. A few of them mentioned that as a medical student or junior doctor they moved hospitals often, so there was a reduced feeling of obligation to report bullying behaviours, as reflected in these two quotes:

As a profession we’re not very static, we tend to rotate very, very quickly. What’s the point of reporting something if it’s only going to last for a max of 10 weeks, you’re going to move onto the next one anyway, and do you really want to develop a reputation of being a whiner who can’t cope… – Dr Nick Riviera

I talked to a few of my colleagues about it and asked whether I should report it, but then we all sort of decided that, you know she’s …we’re not sure whether she wants it reported… – Teddy

Dr Nick Riviera also said, “If he doesn’t think there’s a problem, who am I to say there’s a problem”. Basil suggested that her membership to medical student group would either protect her from having to report the bulling, or render her opinion null: “I think if it did happen I would not report it. I’m just a medical student, and I wouldn’t want to get involved”. When it came to perceptions of reporting, the feelings of fear by the participants were palpable, and this was often coupled with a deep cynicism of whether those who they would report it to would do anything effective about it. These sentiments were reflected in the results from the earlier-mentioned RACS EAG Report, with surgical participants even floating the idea that the RACS commissioned research itself was a ‘whitewash’, or ‘political stunt’ (RACS, 2015b). Comments made by a senior specialist surgeon, online to a recent Medical Journal of Australia article, called the RACS investigation a “ludicrous hand-wringing exercise that RACS has just put us all through” (https://www.doctorportal.com.au/mjainsight/2017/23the-tyranny-of- excessive-medical-hierarchy/#comment-15133, accessed19.07.2017).

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However, a couple of students believed that bystanders do have an important role in reporting. Steve suggested:

The plus side of bullying in the workplace is that someone else can report it, so it doesn’t have to be the junior doctor. Often the people being bullied don’t ever report it and so a colleague of the junior doctors, one of his other staff could report it to management and say ‘this doctor’s being a bullying that doctors here’s what happened

There were also a number of other perceived impacts of bullying that participants mentioned. Rather than see the bullying behaviours as a fault on the part of the individual bully, or the environment, a few participants indicated that their response was to alter, or ‘improve’, themselves. Despite there being studies that highlight the difference in outcome between constructive workplace opportunities that promote positive professional and personal growth, and those actions which erode a medical students sense of competence and welfare (Haglund, aan het Rot, Cooper & Charney, 2009), some participants still felt that abrasive behaviours from senior doctors provided an opportunity to improve. The conceptualisation that abrasive or hostile behaviours by senior doctors could be positive or constructive by medical students will be examined further in Chapter Nine. Rhianna suggested that if bullying “was directed at me, maybe I would talk to someone and try and strengthen myself I guess”. A number of participants referred to the idea that it might be acceptable for qualified doctors to be abrasive or hostile to less qualified doctors, that the impact might in fact be a positive one. Hadley, Christine and Chuck suggested that bullying behaviours could be an effective method of training, motivating and prompting medical students to remember the material:

In some ways I think, I like to be trained by feeling a little bit on the edge, or a little bit scared of my senior doctors. – Hadley

Maybe some people need that kind of ‘mum yelling at the kid’ kind of situation so that they won’t do it (make a mistake). – Christine

It [abrasive behaviour and shouting] is actually a very effective way sometimes of teaching someone a lesson, ummm, but I think it definitely should not be done in public. – Chuck

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For some participants there was an element of deserving the punishment, combined with a perception that the punishment was an effective method to remember what not to do. Rhianna shared: “If I made a huge mistake I wouldn’t mind, I think I’d deserve it. I think, I’m not sure if it’s just my view, but I think I would want to be yelled at so I would really remember”. Ashley reported the idea that enduring bullying at work was going to eventually be a beneficial experience:

I suppose you do get a tough skin and maybe you see that as a benefit. Like later on in life, like ‘thank goodness they bullied the hell out of me cos I can deal with this now’.

Christine thought that the bullying behaviours might provide comedic relief in an otherwise difficult situation, and suggested, “It can almost be a source of humour you know… so I guess there are different coping mechanisms”. A few participants conceded that the abrasive behaviours might be ok for some targets but not for others, perhaps dependent on the personalities of the individual being targeted. This narrative fits with the already revealed themes of bullying producing a tougher, more capable doctor, and of victims of bullying being in some way responsible for the behaviours. There is an unspoken, implicit insinuation in these themes of individual deficit, identified by Ashley:

I think some people might get toughened up, but then other people like myself, and I think some other people, who might be really good doctors...because they have empathy and that sort of thing, really struggle.

The idea that individuals who do not appear to be negatively impacted by bullying, as somehow being more resilient than others who do, was shared by Chuck: “There is a type of person who can take that with a pinch of salt, and say, ‘yes there’s a lesson here’, instead of being personally offended by it and going home …”. Medical students often nominated being tough, resilient or stoic, as a positive characteristic, Steve commented,

I mean you come in and you can either deal with it or you can’t. I’ve seen plenty of medical students cry because of the way they’ve been treated, others are just like, ‘oh well…’ I’m certainly quite stoic.

A few of the participants suggested that the perpetrators of bullying did not fully understand the impact of what they were doing. To illustrate:

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It makes me sad, it’s completely unnecessary and it’s just very mean and they don’t realise the damage that they’re doing. – Rhianna

Maybe the senior doctor is not so aware of the effects of his or her behaviour on the junior doctor. – Oliver

Furthermore, several of the participants felt that the impact of the abrasive incident was not significant enough to report, or that it was a relatively ‘victimless’ offence. Chuck felt that if the patient was not negatively impacted, then there was literally nothing to report. While Ashley argued that, because bullying was such a frequent occurrence, and because senior doctors defined the behaviour as both tolerable, and expected, then the incident was somehow less impactful. Chuck noted:

I know it wasn’t a good incident, but I don’t think it would have had any impact upon the patient and because of that, it is wasting the time for everyone reporting and my own time going to report it…and then tell someone about it, and follow it up.

Ashley commented, “It’s just kind of accepted that you have to ‘get over it’. Like if you kind of say something, they’re like, ‘oh so what, that happened to me all the time’, or, ‘… and I’m fine now’.” Despite the research, outlined in the earlier chapters, which indicated the potential negative effect of bullying on patients, only a couple of the participants articulated a connection between bullying amongst doctors and unfavourable patient experiences. One of these medical students shared an incident where the patient was left unattended in the wake of an abrasive incident, Lily postulated about the impact: “I could have sworn there was evidence out there that if you treat your juniors with respect and have, like an open dialogue then patient outcomes are better”. Mathalda reported that in one confrontation between doctors, the patient they were arguing over:

looked a bit uncomfortable…and confused because obviously they are now getting two messages (about treatment)… they should not have been bringing their own personal … biases and dislike for each other to that ward round in front of the patient.

Some, but not all of the medical students, shared their insights on the perceived negative impact of bullying, including extreme impacts:

You hear, just in February, I think, four Interns committed suicide, or something ridiculous, and if they don’t seek help, that can happen. It’s terrible. – Ashley

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Anxiety, humiliation, doubt, anger, frustration. – Christine

7.8. Conceptualisations of better alternatives

While most of the participants indicated their perception that the prevalence of hostile behaviours was simply too high, this notion of an elevated level of hostile interactions is often coupled with the concept of hope, and the idea that there must be a better way to interact, communicate or behave. While Chapters Two to Four unpack studies, some of which offer suggestions for improvement, there are no known studies that focus on the concept of medical students perceptions of hope or optimism or even prediction for the future of bullying in medicine. Matilda saw the future in this way:

The more I’ve spent time in the hospital and seeing interactions between doctors who don’t bully their colleagues or speak to them condescendingly, I realise that it doesn’t have to be done that way and there is an alternative.

Hadley mentioned the idea that, in the future, doctors will be willing and enthused about teaching medical students:

I have expectations of myself becoming a senior doctor eventually, one day. I hope I take the good bits and I hope that I leave out the bad bits. I hope to be willing to teach and be committed to it.

Amelia suggested that definitions of bullying are something, which “needs to be taught, and it needs to be very clearly outlined and perhaps education programs need to be mandated or something”. And Steve noted a different reality was possible:

I have certainly been in situations in acute care, emergency situations where there is no yelling and it’s just stated calmly and it still works. No one needs to be yelled at, it doesn’t help. It just upsets people and scares people, gets them in the wrong frame of mind.

A number of participants felt that addressing an issue of medical student or junior doctor competence is always best done in private. This idea fits with what they had conceptualised around the definition of bullying. Some participants also suggested that there was no need to raise voices, and that forewarning medical students of those tasks in medicine which may elevate stress levels, and precipitate abrasive communication patterns, may be helpful. For example, Teddy noted that “There are

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other avenues that you can take to tackle the issue differently, you can talk to them in private”. Amelia observed,

I think that even if that student had done something wrong, which had severely compromised patient care, there is a way to go about that in a constructive, respectful way, and also taking some of the responsibility and recognising that perhaps there were other parties at fault.

The idea of senior doctors showing consideration, respect and discretion was raised by a number of the students, by a number of students, Lily shared,

I had one really nice interaction with one of the senior Regs in theatre once, where before we went in he said, ‘look when I’m operating I might get a little bit snappy with you’, but know it’s not because you’ve done something wrong, it’s just because I’m under pressure and that’s why…”and I thought it was so considerate, just so amazing…and it really made me feel so much better about the environment that I’m going into.

And Steve noted,

I mean to be a doctor you have to be fairly intelligent, so I think we are all quite capable of not yelling at people and dealing with it in a calm and thought out manner.

A couple of students also mentioned the role of the hospital in ensuring a better alternative. This matches with what surgical doctors and trainees reported in the RACS EAG investigation, with participants having suggested that hospital management was “uninterested in addressing bullying issues”, and that in some cases they were also unwilling to intervene (RACS, 2015b, p. 38). Amelia felt that hospitals:

have a responsibility to address that (bullying), and to do everything possible to provide a supportive workplace for all employees and to ensure that people know who to contact, that there is help available and also a very transparent reporting process accessible to everybody.

7.9. Chapter summary

The findings in Chapter Seven highlighted the wide range of medical students’ conceptualisations surrounding bullying behaviours amongst doctors. Most of the participants believed in a generational influence on the prevalence of bullying as well as

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medical students inability to step in and stop, or report events of bullying or hostility amongst doctors. Some participants keenly felt that doctors needed to remember what it was like to be a medical student. Results indicated that while most students believed that they might eventually be able to affect change, they also felt that this could only be achieved once they became consultants or in a position perceived as higher up in the organisational and professional hierarchy. Similarly, there was some continuity of participant response in conceptualisation of prevalence, impact and definition of bullying. All participants described being fearful of a range of negative consequences if they were to formally report bullying or abrasive behaviours by doctors. Furthermore, while most participants felt that the impacts of bullying were predominantly negative, there were also some medical students who perceived that elements of the hostile behaviours might have been positive or useful. Notably many aspects of the participant conceptualisations of definition differ from objective, or operationalised definitions. The vast majority of perceptions shared by participants were individual in nature, rather than collective. Chapter Eight will now explore behaviours experienced by medical students and the context in which they occurred.

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Chapter 8. Experienced behaviours and the context in which they occur

Chapter Eight presents the findings in relation to behaviours that the participants have either being directly involved in, or witnessed in some capacity. The behavioural themes in this chapter differ from the conceptualisations or perceptions reported in Chapter Seven, as they are descriptions of the events directly experienced by participants, versus the beliefs or interpretations of workplace bullying that the participants have identified in the previous chapter. This chapter presents findings associated to the participants’ views of positive behaviours, overt and covert bullying behaviours, in particular, the behaviour of ignoring. Insights into academic humiliation are also presented, as well as experiences that fall outside the existing definitions of workplace bullying. The chapter explores communication patterns amongst doctors, and the participants’ experiences of teaching and mentoring are also considered. Descriptions of incidents of sexism and sexual discrimination, and descriptions of experienced or witnessed impact of abrasive behaviours are examined. The notion of context is discussed, including participant insights surrounding the connection between workplace bullying and environment. The data from this chapter relates directly to question two of the research, ‘what are some medical students experiences of bullying amongst hospital-based doctors?’ Furthermore, the data relating to perceptions of context can be linked to questions threes focus on contributing to our understandings of power and oppression.

8.1. Behavioural interactions

Most of the participants were keen to reiterate that the majority of interactions experienced and witnessed amongst hospital-based doctors were positive. While there are no other known studies, that explore medical student perceptions or experiences of bullying by doctors, as contextualised in a spectrum of behaviour, the RACS EAG research suggests that surgeons also felt that “the vast majority of consultants have been supportive and good role models. As with any profession, a few rotten apples will spoil the cart” (RACS, 2015b, p. 27). For the participants in this study, inclusion was a recurring theme that came up when participants were describing positive interactions. Some of the medical students’ positive experiences are documented below:

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Christine said, The consultant would include us in the team. When a Unit includes you it’s really great. Chuck shared,

It is important to keep in mind that the interactions that I have described are probably two out of hundreds, if not thousands of interactions and that the vast, vast majority of interactions are positive.

Lily also suggested,

The interns and the registrars that I’ve worked with this year have been an absolute pleasure to work with…most of the consultants have also been great…

At the opposite end of inclusion is exclusion, specifically the action of ‘ignoring’ as a form of covert or ‘passive’ hostile interaction, which was widely reported by participants. It was suggested that doctors higher up in the organisational or professional hierarchy, mostly perpetrated ‘ignoring’ behaviours. Ignoring, or isolation is a documented form of bullying, with a study published in the Postgraduate Medical Journal reporting that “freezing out, ignoring or excluding” (Stebbing et al., 2004, p. 93) were all common techniques employed to bully training and junior doctors. Additionally, a recent Australian study exploring medical student experiences of academic humiliation also found that the majority of behaviours reported are “subtle rather than overt” (Scott Caldwell, Barnes & Barrett, 2015, p185e.2). Abigail reported that after a six week rotation on the cardiology ward, the registrar “didn’t look us in the eye, she didn’t even ask our name, we tried really hard. We asked questions. We would get there in the morning and she would ignore us. We kept turning up, we turned up at 6.30 every single morning, it was an hour and fifteen minute drive, and we tried, but she wouldn’t even look at us…”. While Dr Nick Riviera said, “You’re an anonymous person”. The ignoring of medical students was not without impact. Many participants mentioned an accumulative negative impact to being ignored on a regular basis. The purposeful exclusion of medical students could be considered, on one level, as a process of dehumanisation. Amelia said, “You can feel quite small at times. There is also the ignoring that goes on by some doctors and you feel a bit expendable, or a bit like wallpaper”.

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Described experiences of abrasive incidences

All of the participants described first hand experiences, as either a target or witness to abrasive behaviours amongst medical doctors. Many of the incidents that participants described outlined the tone of voice used, or the content, which was often sarcastic or demeaning in nature. Some of the participants mentioned power differential in the incident, and others reported an attempt to attack or undermine the other doctor or medical students’ professional capacity. Some of these incidents are included below:

The doctor I’m talking about is a cardiologist in B. Hospital, he had just moved into B. and ummm…sort of had a high position, he was the medical director…he didn’t shout, it was sort of like, more sarcastic language that you use, more like his tone was aggressive… – Teddy

Ashley also shared her experience,

The big one I can think of was in third year medicine, and I was out B. way, umm, and yeah, I was told to do some kind of examination on a patient and I did it to the best of what I could think of, and the consultant was a neurologist, and she cracked it at me in front of the patients, and told me I was incompetent, and this and that, that I should know these things, and blah blah, blah, and I just kind of broke down and started bawling my eyes out, and the patient was like “leave her alone!”…

Dr Nick Riviera reported on an incident that, “It can be almost passive aggressive in the way they act. Almost barbed responses”. While Steve said, “There was a bit of raised voices. Demeaning…no swearing…no ‘you’re a fucker’, but certainly demeaning… ‘You are just scum of the earth, you’re an intern you don’t know anything…” . A number of the abrasive incidences shared by participants centred on the academic humiliation of medical students or junior doctors. As unpacked in the earlier chapters, this practice has been highlighted recently in a number of studies, with a meta- analysis of 51 studies finding that the most common form of harassment included verbal and academic (Fnais et al., 2014), additionally academic humiliation is reported by junior and training doctors worldwide. A term used to describe the behaviour of academic humiliation in America, and which is gaining increasing currency in the Australian vernacular, is ‘pimping’ (Kost & Chen, 2015). Pimping refers to the practice of senior doctors asking junior doctors unreasonably difficult questions, in a public context, often asked in an aggressive, rapid sequence, and conceivably with the “intent to or humiliate the learner to maintain the power hierarchy in medical education”

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(Kost & Chen, 2015, p. 20). Most of the participants of this study indicated having witnessed or being at the end of, such hostile questioning. What follows is a selection of incidences that participants shared, although I feel that Abigail’s story below captured this practice perfectly:

So a friend of mine was doing heart surgery, not doing it, she was watching it. She was asked to hold the heart while the open-heart surgery was taking place. She said it was amazing, but what happened was the surgeon kept asking her questions. They were really hard questions; questions that are like any third year medical student …no one would know this. She was like, ‘arghhh…’ He had his head down. All of a sudden, she realised that the anaesthetist who was on the side next to her was whispering the answer to her. You know he’d ask a question, and he’d (anaesthetist) it. The surgeon kept asking questions, and she got them all right, then she had to move to the other side of the person, so she wasn’t next to the anaesthetist anymore, so she’s freaking out that she was not going to get the questions right. Then he asked another question and the anaesthetist started scribbling the answer down and holding up the piece of paper to answer it…

Abigail continued,

Then she saw the anaesthetist a week later and came up to him and said “thanks so much, you really saved me in there”, and the anaesthetist said ‘yeah, I’ve seen him ask the same questions to every single medical student, yelling at them when they get them wrong…and the questions are ridiculous’. So he started to memorise the answers and he said that the surgeon came up to him (the anaesthetist) the other day and said ‘you know these medical students are getting better’!

The story by Abigail touched on a number of the key elements of academic humiliation. Namely that the questions asked were purposefully too difficult for a student at her stage of training, that the incident occurred in front of others, and that, should the student get the questions wrong, they would be humiliated further by being shouted at. While the story also captured a sense of camaraderie between the medical student and the anaesthetist, it also pointed to an assumption that the anaesthetist had not been able, or successful in confronting the surgeons’ behaviour. Oliver also shared an experience:

One which I witnessed was between another medical student and a senior doctor consultant, and what happened there, basically was the consultant was very sort of, was meant to be teaching but went about it very harshly, and was condescending and tore

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down everything the medical student said to the point that the student actually began to cry.

Ashley shared her involvement with being bullied. Ashley was visibly emotional when she disclosed aspects of her story, “It was just belittling me…she was saying, overall, ‘why are you here, why are you doing medicine. You’re not meant to be a doctor!’ So yeah”. Christine also reported:

It’s called being pimped, you are asked questions you’ve just got no idea what the answer is to them, and then being humiliated in front of other people... it brings back sort of memories of that happening to me…

Some incidences shared by participants, as their examples of abrasive or hostile interactions sometimes fell outside the bounds of an operationalised or academically accepted definition of ‘bullying’, but nonetheless were still considered, by the participant, as equally negative in outcome. Although many of the participants suggested that bullying should be repeated behaviours, a number of the medical students nominated an experience of bullying or mistreatment, which was a one-off occurrence. The lack of a consistently applied definition of workplace bullying is a strong thread that was in evidence, from the examination of literature in the earlier chapters of the thesis, through to the participants’ responses. Below is an example of such a one-off incident that was nominated by participant Oliver:

…I guess that (the incident) also involved a much senior doctor and just…sort of blurring lines around consent, it was meant to be a demonstration for a medical class of just an examination to perform, and I guess the long and short of it is that I had to remove my pants for it, which was like…it was blurred lines for consent because I did consent to it, but the doctor was so much more senior, I sort of felt inferior as the medical student…that this is what I had to do for the teaching...But then after that happened I sort of realised that that did not have to happen. I should not have had to remove my pants…I mean I laugh it off now, but I guess after it, it was just knowing that I probably shouldn’t have…

8.2. Communication patterns amongst doctors

Most of the participants spoke of unwritten or ‘secret’ codes of conduct, or rules amongst doctors. Participants reported that it was important for them to follow the covert rules. Only a couple of the students articulated what might happen if those rules

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were not followed, however most just infer that it was best if they were adhered to. When asked about what might happen if a medical student did not follow an unwritten code of conduct, ‘Dr Nick Riviera’ suggested that “you generally get taken off to the side and get completely chewed out”. These unwritten rules were referred to in one document as “social etiquette” (AMSA, 2015, p. 5), and could be considered a set of clandestine rules, inherent in which is the implication that some individuals will have knowledge of them, and others will not. This links with the concept of a hidden curriculum within medicine and medical education, which was explored in Chapter Three. Moreover, the situation where some individuals have access to that knowledge and others don’t potentially connects with the notions of exclusion, trust and professional rivalry. Below are some of the insights shared by the participants, on the different codes of communication and conduct found within medicine. Amelia said,

I think often they (senior doctors) will set the tone of the conversation and… it’s sort of an unwritten rule…you know this is hierarchy and you kind of have to observe it.

Dr Nick Riviera also suggested that,

There’s an unwritten rule that if you have grievances with another doctor, you address them in private. As a first year med student we had a nice medical fellow who actually took us aside one day and said ‘O.K. you’re in the hospital now, it’s a scary place here are some of things you can do and can’t do…. You don’t walk around the hospital eating food, if someone asks you a question the answer is always 10% or 70%, and if you have a problem address it in private.

On the acquisition of certain unwritten rules regulating expected behaviour of medical students and trainee doctors, Ashley reported, “I’m not actually sure if it’s just other students providing feedback, or…I’ve just sort of picked it up at the time. So I don’t know if it’s been from lecturers and that…it’s just kind of known…”. In terms of professional or organisational expectations and norms, Basil suggested, “I don’t think there are written rules, they’re probably just implied” However, Christine said that they were given a briefing of sorts, “Ummm, we’re kind of told it. A soon as we start at the hospital, they’re like ‘ok, just a heads up, you should do this, this, this…”. On broader influences on understanding the unwritten rules Dr Nick Riveria said, “I also watch House, Scrubs and Grey’s Anatomy. So a lot of those rules…they kind of try to express them in TV shows as well”. Interestingly one of the other male

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participants also referred to these television shows as accurately representing communication patterns and behaviours in the medical profession. A number of participants shared the presence of formal communication channels and informal channels. While most participants said it was vital to follow the chain of command when communicating upwards in the professional and hospital hierarchy, many of them suggested that horizontally the lines of communication were often more blurred. Many of the participants suggested that within their generation of doctors, interactions amongst medical students and trainee doctors at the same hierarchical level were generally positive. As Amelia shared: “with my medical student peers, mostly positive and supportive”. Abigail also suggested that there was “a lot of camaraderie with the students. People really look out after each other…”. Lily said,

Being in a hospital network for sometime you just end up working with your mates, so what would have been a formal mode of communication just kind of becomes a text message saying, ‘oh can you come see this patient for me’…’there’s these ways that really depend on the relationships that you have, and your past history with other colleagues.

Most participants reported that formal communication was almost always levelled up, towards senior doctors, not down. This is in line with other studies discussed in Chapters Two and Three. To illustrate this perception Lily reported: “There’s the division of communications between colleagues who are senior to you and the respect that you just have to inject into the conversation” Lily continued, “It’s funny cos a consultant once said to one of the medical students who was on a rotation with him that when emailing him they needed to be, I quote ‘reverential’…”. Matilda also suggested,

There’s a proper way that you’re meant to communicate and if you don’t perform to that sort of efficient way of communicating then you’re not held in good regards. If you are addressing someone who is your superior there is a certain way that you need to go about it.

In terms of medical students and trainee doctors following expected protocols, and processes, Dr Nick Riviera revealed, “There is a formal and an informal process”. According to Lily, talking to a consultant was “like how you would speak to your mum when you first meet her. Like it’s very formal, very polite, and very open to changes…and a lot of qualifiers as well”.

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A number of participants also spoke of a sense of duplicity, which was intrinsic in much communication between doctors. The theme of deceitfulness fed back into the idea, that some medical students and junior doctors seemed to be privy to the ‘unwritten rules’, or ‘social etiquette’ of medicine, while others appeared to learn these rules only once they had infringed them. As noted by some participants, the medical profession can be competitive in nature, and this competition is coupled with a documented fear of retribution (Kassebaum & Cutler, 1998; Dyrbye, Thomas & Shanafelt, 2005; Rees & Monrouxe, 2011; Fnais et al., 2014) for transgressing visible or unseen organisational, professional or institutional norms. These elements combine to provide the perfect context for duplicitous communication and behaviours to thrive. Broader discussion on duplicitous communication, and other unprofessional actions amongst doctors, both qualified and training, suggest that structural or contextual failings within teaching environments also foster poor behaviours and practices in doctors. One study posited that unprofessional, deceptive practices in medicine started early in a doctors medical career with the “disconnect between the explicit professional values they (medical students) are taught and the implicit values of the hidden curriculum” (Brainard & Brislen, 2007, p. 1010). Brainard and Brislen argue that due to unprofessional conduct by those in positions of authority, medical students were taught to ‘compromise’ professionalism, and be ‘flexible’ with their principles, and suggested that many students felt that medical training was “infused with “opacity, duplicity, and politics” (Brainard & Brislen, 2007, p1012). Below are some of the participant experiences relating to duplicitous behaviours: Lily observed that doctors treated patients and colleagues very differently, “I don’t believe that you can be so respectful and kind to your patients and then treat your colleagues like crap. It’s the two-facedness that I find astounding”. A number of the participants shared accounts of duplicity amongst doctors themselves, specifically those from different specialties, and those doctors who had made formal complaints against a colleague. Steve shared, “They all know it happens, they all know each other bad mouths each other, but it’s never to each other’s face…most of the time”. Steve continued his commentary, “There’s a lot of whinging and carrying on to each other and then… ‘Hi how you going, you’re amazing’ when you interact in-between”. Mathalda reported, “I don’t see a lot of (overt) abrasive things between other people but I see a lot of talking behind backs…”. Steve suggested that,

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It doesn’t happen directly to the victim…you know it’s like the victim is over here and the other people are talking amongst themselves and they’re quite overtly saying ‘oh they are the tattletales, but then they’d be all smiles to that person…

8.3. Teaching and mentoring

As shared by some of the participants, experiences of abrasive behaviour might be seen as an effective way to teach, and learn. The vignette below illustrated how an experience of abusive behaviours was reframed as teaching by the registrar, and then imprinted on the medical student sharing the story. The medical student also suggested that he now always reframes abrasive behaviours in a positive light. This is consistent with a number of reports that suggest an institutional and professional process of enculturation, which in turn may lead doctors to believe the idea that the abuse is an accepted, or even productive part of studying and practicing medicine (Scott et al., 2015; Major, 2014; Rees & Monrouxe, 2011). Chuck shared:

I was in theatre once, probably 2 years ago now, there was this surgeon who was always raising her voice and got quite angry at the Registrar doing the surgery for various reasons, and afterwards I asked the Registrar, ‘how did you feel’?, expecting the person to say, and talk about how bad they were, and they turned around and said ‘no, it’s great because that is how you learn’. Since then, that’s how I approach being…’grilled’ by someone senior, It’s a learning opportunity for me, it means they are engaging me. It’s to my benefit not theirs.

Chuck continued by saying,

At the time, I would have thought that surgeon was really mean etc., but having had that experience, and if it happened to me now, I would probably be in the same shoes as the Registrar, and think of it the same way as the registrar.

Chuck documented a process, in which a senior doctor defined the experience for him, letting the medical student know, that the culture is one, which defines abrasive behaviours, as ‘learning opportunities’, rather than bullying. Further to Chuck’s story is this account below, which illustrated the impact of Lily witnessing abrasive behaviours on her future interactions with senior doctors:

I felt he just kept labouring it (resident who was disagreeing with a consultant) and in my head I was thinking ‘shut up’ (laughter) just shut up!! Let it go. Stop talking!! I take

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it like a learning point kind of thing, and it’s shaped the way I would interact with senior doctors.

Lily suggested that the abrasive incident she witnessed, where a doctor more junior to the consultant questioned the way the consultant approached a patients’ treatment meant that she was now “less willing to question it”, a senior doctors authority. Lily shared,

I’d say something along the lines of ‘I hear what you’re saying and it makes sense, but I was wondering if ummm…I’d propose it, like what do you think about this idea, and can you explain to me why the way you’ve done it would be a better option…just so I can learn…

Conversely a few participants mentioned that the greater the exposure to different communication styles, the more they learnt of other, more effective and less abrasive ways of communicating. Many of the students mentioned the power of having good or positive mentors throughout their training and junior years. Mathalda shared,

In terms of my own kind of faith being restored in the profession, it (mentoring) was really important that when I actually encountered doctors who I found to be very inspiring, in terms of their practice and their approach to patient care, that was really important to me to see that there were professionals that did their job in the way I thought it should be done. So I think mentoring is really important.

Mathalda expanded on her insights,

Good mentors are good. Sometimes bad mentors they can be handy and tell you what not to do, if you look at them and see what they’re doing that you don’t want to be, you can look at your own behaviour and make some changes.

Christine also described a good mentor relationship as,

Kind of… I don’t know... master and the grasshopper sort of relationship with all the senior doctors…so when they involve you and treat you like a person and realise what goals you have as a student, it’s great.

However, what one person might define as an abrasive or adverse interaction might be another person’s definition of a positive interaction. The subjective nature of interactions was highlighted, in relation to the above example of Christine’s positive mentor, with a 2011 qualitative study on abuse of medical students (Rees & Monrouxe, 2011). The study gave an illustration of direct , including “being called

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derogatory names by their physician teachers emphasising their lowly status e.g., “grasshopper,” which is juxtaposed with the insight Christine shared on what she considered a positive relationship, a “master and the grasshopper sort of relationship” (Rees & Monrouxe, 2011, p. 1377).

8.4. Described incidents of sexism and sexual discrimination

Many of the participants shared perceptions and experiences of sexism and sexual discrimination. Participants’ perceptions on cause of sexism and sexual discrimination have been addressed in the previous chapter, however this section aims to share some of the additional experiences of sexism that many of the female participants share. Many of the experiences described, related to three categories, out dated sexist stereotyping such as ‘females shop a lot’, or ‘all females working in healthcare must be nurses’. Others described inappropriate sexual overtones in conversations between senior male doctors and junior doctors, and some participants told accounts of how female junior doctors were still overtly discriminated against for traditionally male specialties. Below are some examples of participants’ experiences of sexism and sexual discrimination. While most of the instances occurred within a hospital context, others occurred in broader settings such as private consulting rooms or even within . When Ashley missed clinical classes for a psychiatric appointment, an appointment, which was prompted by the bullying she had experienced on placement, she shared,

They were really concerned that I was “out shopping” and I was just like…. that was really offensive. It was … I was having an interview with the Head of Year 4 who is a paediatrician.

Christine reported that, “People assume I am a nurse or a nursing student…not that it’s a bad thing, just that those assumptions still happen”. Amelia also shared this insight,

One of my friends who is in the year below me was in theatre and was scrubbing up for surgery with another male Registrar…then a senior doctor walked in and was sort of winking at the other doctors and was saying, “oh well, she’s quite pretty, I can see why you’ve chosen her’, and of course she felt incredibly small and you know, not valued as a professional trainee doctor.

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One participant not only described a conversation, which included inappropriate sexual content, but also added that sexism and harassment continued in certain rural hospitals due to a lack of alternative options. Rhianna shared an incident that happened in a remote Australian hospital, “Just an incident in B. Hospital, the orthopaedic surgeon was making very sexual jokes to the theatre nursing staff, and he was actually making noises...like really immature, and doing the action of ‘the act’. It was just so terrible and they didn’t say anything. He was a locum as well so they had that pressure you know, they had to keep him”. Some of the medical students also felt that sexism was still evident in the current cohort of medical students. Amelia said, “So medical students…often there’s a lot of sexist humour, there have been rape jokes which have been put up on . Condescending remarks and males, ‘oh honey’, and things like that”. Below are three examples of experiences related to sexism and choice of medical specialty. Most of the female participants who raised the issue of sexual discrimination mentioned this kind of ‘career advice’ being offered up, and most ‘advisors’ were reported as senior male doctors. Abigail reflected,

Females are treated terribly…as a female doctor. The amount of times doctors or anyone tells me I should be a GP; it’s a really good profession for someone who wants children. That happens all the time.

Rhianna also shared an interaction she had with a cardiology consultant who offered her some ‘career advice’ based on her presumed ability to produce offspring,

That Consultant said to me ‘do you want some career advice, and I was like ‘yeah sure’, and then he said ‘go be a dermatologist or an ophthalmologist’, if you want to be a mother and raise your children go do those, they can earn heaps of money for doing not much’, I was like, ‘what if I want to do surgery or cardiology’. He was like, ‘well I’m the breadwinner for my family, so I have to do that, but you’re a girl’.

While a number of the participants suggested that sexual favours were sometimes traded for career progression, the medical students never elucidate this notion. Abigail reported,

It’s a commonly known thing, not that I knew, ha-ha, but someone else told me that the way to get into training programs is to sleep with the consultants. That’s a commonly known thing.

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8.5. Described impact of abrasive incidences

The stories shared in this section are descriptions of witnessed or experienced impacts. They differ from perceived or intuited impact or effects of bullying amongst doctors. Described impacts generally fell into two categories, most participants who spoke about impacts told of negative psychological, emotional or physical consequences for individual healthcare workers including themselves, however a couple of the participants discussed negative impacts on the patient involved or present during incidences of workplace bullying. Any description of impact on a group level was discussed more in terms of cultural silos, meaning particular wards, units, hospitals, educational institutes, professional bodies having difficult, pleasant or competitive cultural . However, even in descriptions of culture, most participants suggested that it was individuals who exerted the biggest influence over the organisation or professions norms, values and beliefs. Participant accounts of cultural silos are explored in section 8.6 of this chapter. None of the participants acknowledged the potential negative collective impacts of workplace bullying on the medical profession as a whole. This response was in keeping with another study that found the vast majority of medical students interviewed, nominated individual factors as both contributing to, and being effected by ‘abuse’ amongst qualified and training doctors (Rees & Monrouxe, 2011). The following quotes come from participant narratives on the experienced impact on medical students, doctors and other health professionals. No participants reported that they had experienced a positive impact of bullying. A number of the medical students reported adverse emotional and psychological impact from the bullying behaviours. Teddy shared, “I think I was just scared, ummm…he…was a scary doctor anyway and we were all like scared of him and this incident…it just confirmed it” . Ashley added that, “I actually ended up developing a social anxiety, and I was actually, um avoiding these sorts of scenarios…”, while Teddy shared an experience of bullying that had happened during surgery, “The surgery had finished and I went into the change room to get out of my scrubs and she was sitting there crying”. Abigail made the observation that,

All medical students cry a lot, when they come home and they’re alone, or in the car on the way home. Everyone cries just from the pressure of the day. There are so many

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people who have developed depression and anxiety over the past couple of years…it’s really hard to see.

While Lily captured the sense that watching someone being bullied had an impact on everyone who was present, “Just seeing that, like I felt I’d definitely witnessed something that was very private, and I felt like quite embarrassed that I was there”. Lily continued to share the way that an earlier abrasive incident made her feel, “The first one was definitely a bit scary to watch…I’ve never seen something like that”. Incidents of bullying behaviours undermined the medical students professional competence, and sometimes triggered a sense of being a that some say has lasted with them. Ashley shared,

Oh it definitely made me question my competence. Like, again, because of my confidence, and I don’t know, if it’s poor confidence because of little things like this, over time…I s’pose it’s stayed with me…it did really upset me.

Matilda disclosed how being bullied on a clinical placement affected her,

It made me feel very ummm…quite afraid of…and scared…like I used to get very anxious that I was going to get put on the spot and that actually …I just felt really inferior all the time and like I was useless, and that I was a fraud even doing medicine and it actually spiralled. That year I actually got very sick, I was diagnosed with an anxiety disorder and quite severe depression as well. So for me those very negative clinical interactions have had quite a profound effect where I actually had to take a year off uni to actually get well again.

This experience of permanent negative impact was also acknowledged in the AMA EAG report, which noted that a number of surgeons of “mature and senior years” could still vividly recall being bullied as a trainee (RACS, 2015b, p.29). Other medical students reported that they felt a range of emotions from being purposeless, angry and sad: Chuck said, “I think I felt how she would have felt, sort of a bit ignored, and sort of a little bit purposeless”, while Amelia was one of the few medical students who expressed anger, others had mentioned frustration, or . This is what Amelia shared: “There are some attitudes and remarks that just shouldn’t be tolerated, and I mean that makes me feel angry”. Lily reported that abrasive incidents that she had experienced, witnessed and heard about made her feel sad, “It makes me feel sad. Like overall sad. Like it’s not fair. No one has the right to belittle you”. Matilda revealed that, “I witnessed some very

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negative interactions between senior consultants and junior doctors, where the junior doctors were basically dressed down in front of everyone and almost reduced to tears and that had a very negative impact on me as well”. While Ashley shared that the abrasive interaction with the neurologist had impacted her choice of specialty,

…That definitely would have put me off, and I think that’s the same with surgeons, because I being in theatre, but the communication and the surgeon’s demeanour is very off-putting.

While no male participants mentioned being put off a speciality because of an experienced gender imbalance, or sexist behaviours, Ashley was not the only female participant who disclosed that they had been put off surgery after their rotation, because of behaviours or attitudes encountered in the heavily male dominated environment. This observation by the female participants was congruent with research conducted in the 2015 RACS investigation into bullying, harassment and sexual harassment in surgery (RACS, 2015a, 2015b). Teddy shared that it was the fact she did not speak out about the bullying that had impacted her, “You know, I didn’t say anything, so when I look back to it I feel like I should’ve said something”. Teddy further reported, that upset after an incident of bullying,

The radiographer actually left the room, yeah, and sort of like left the patient, yeah just like on the table for a good 5 to 10 minutes before they actually went and got him…

Chuck also described an incident where two doctors argued over the best course of treatment for the patient, while ignoring the patient,

I would call it…not a miscommunication...but just an overall lack of communication, sort of ignoring... Sub-optimal. I wouldn’t want that if I was the person, if I was the patient.

8.6. Context

The next section of this chapter focuses on participants’ understanding of their occupational context, and the environment in which the bullying occurred. Analysis of the interviews revealed that participants paid particular attention to two contextual dimensions, the medical profession itself, and the perceived culture in which bullying or hostilities occurred. Workplace culture, in this instance referred to the predominant values, behaviours, traditions, norms, beliefs, interactions and attitudes of those within

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the organisation. While most of the participants appeared to speak about particular organisational or institutional cultures with some confidence, two of the participants sought clarification around what was meant by culture in relation to point six (6) of the participant interview guide. Situated within the ‘key concepts’ section of the interview schedule, question 6 asked ‘do you think that your workplace or profession has a particular culture relating to workplace intra-colleague interactions? Tell me a bit more about that culture. How would you describe it’? The interviewer’s response on both occasions was to suggest that in this instance culture was “referring to prevalent values, norms and attitudes within the hospitals, medical professional or other institutions in which the medical students conducted and witnessed intra-colleague interactions”. Looking at the participant responses regarding environment it became apparent that the context, in which doctors, both training and qualified, functioned, was simultaneously equally highly complex and highly influential. How a clearer understanding of context, and its associated structures, processes, practices and resultant culture, could lead to an enhanced understanding of medical student experiences and perception of bullying amongst doctors, will be unpacked in Chapter Nine.

Knowledge of organisational policies

Most of the participants responded as having no knowledge of hospital policies regarding expected employee or intra-professional behaviour. Those medical students who reported having knowledge of the policies professed that it was generally a limited knowledge. Christine shared, “I’m not really familiar with what policies they have…but I find generally speaking with policies, ummm, again, not everyone, some doctors sort of ignore policies”. While Chuck made an observation about what he imagined organisational policy might include, “interactions are meant to be you know…polite and there’s not meant to be any bullying, that kind of thing…”. Oliver was forthcoming in his lack of policy knowledge, “I don’t know any of the actual policies…its assumed that some things are not right…”. A couple of medical students thought that hospital policies around expected behaviours might encompass romantic relationships between patients and doctors, but not in respect to regulating behaviours between colleagues. Sally said, “I would guess there are some policies like or something, but I’m not sure…no, nothing I am aware of”.

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The medical profession

All of the participants spoke about the medical profession in some capacity, however, there were three consistent themes that emerged regarding the contextual nature of the medical profession, and these are, defending the profession, enculturation process, and projected image. These themes extended the notion of professional hierarchy, mentioned by most of the participants in Chapter Six. Many of the participants were keen to emphasis the positives of the medical profession. Some spoke about a sense of camaraderie for those working within the medical profession, and other participants reported sharing a sense of having survived very stressful times together, and of the hope that they will all come out at the end of the process relatively unscathed emotionally or psychologically. Abigail spoke of a bond, amongst doctors,

If you meet someone who otherwise you have nothing in common with, if you both do medicine, you have everything to talk about and it’s really nice. There is a bit of camaraderie, quite a lot actually…

A number of the participants spoke of a communal imperative to survive, that they were connected through a common challenging period in their life, and that they were forever bonded through that shared adverse experience. Teddy said, “The code that they understand just like you, they are just as vulnerable as you, and you’re surprised that they’ve probably gotten through the exact same thing”. Ashley shared,

Because we want to be good doctors, and we want to go far in our careers, and a lot of that depends on who you know. And a lot of the times just getting through it, and then you know come out the other end, in one piece hopefully.

Towards the end of their interview, and often after the participants had shared a negative experience or perception, some medical students wanted to emphasis that doctors and the profession of medicine were not all bad. At times during the interviews, there appeared to be an element of for having shared negative experiences of medicine, to someone outside the profession. Perhaps in doing so, they had broken another unwritten code amongst doctors? Christine said, “I hope I didn’t paint too much of a negative picture”. Likewise, Abigail shared, “I do really want to give a positive …being a medical student is unbelievable…”.

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Differing from the early discussions of perception of contribution, many of the participants qualified or defended the doctor’s abrasive or hostile behaviours. Abigail mentioned,

A lot of them (senior doctors) are very, very busy, they have no time for students, we are parasites who just tag along, it’s very hard for them to find any time for us. To be honest I understand… It’s true we are annoying, we just sort of tag along, and we can feel that we’re annoying.

Chuck shared that although he had been pre-warned about the reputation of a consultant for being a bully, his behaviour was possibly justified or defensible “I have heard about this Consultant… but it could just be they’re having a bad day…It might just be the day, might just be the personality”. Although Abigail had earlier shared the experienced negative impact of bullying, she also suggested that a doctors abrasive, or bullying behaviours was something which “You kinda can’t blame them all that much”. Christine suggested that bullying behaviours were, “sort of understandable if the senior doctor is like tired and stressed, and under a lot of pressure…”. Interestingly, Rhianna mentioned how the medical educators at her university have already started making exemptions for the behaviour of senior doctors, telling the students “sometimes they might be short with you, they might seem to be angry at you, but just know that they are busy…”. Many of the participants spoke of a gradual process of enculturation that occurred over time; progressively shifting their perspective of what they felt was acceptable professional behaviour for doctors. Participants suggested that the enculturation process occurred throughout their medical career, from the earliest days of training. This is consistent with studies that suggest medical professionalism, which can be considered as a guiding framework including such values as respect, integrity, excellence, honour and accountability, is learnt through observation of behaviours at the commencement of their medical studies, (Bourgeois et al., 1993; Lempp & Seale, 2004; Brainard & Brislen, 2007). Reflecting back to the participants’ earlier accounts of hierarchy, and its correlation with their ability or inability to influence others, a picture develops of a parallel process of shifting professional values. Below are some participant accounts that highlighted the medical students’ thoughts around the enculturation process. Ashley disclosed:

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We go from innocent little medical students who are in awe about everything, and we’re like we’ll never treat our patients like that, and then we get to that stage and we’re like doing that! I’m not 100% sure about what happens along the way, but I think it’s just a lot of experience, and pressure, and stress maybe.

Oliver observed that part of the enculturation process was, “Just understanding how the hospital works, the hierarchical system gets implanted in your mind and dealing with it...I see things as more acceptable than I did when I was in first year, just I guess because of desensitisation to it all”. While Basil illustrated her shift in tolerated behaviours; “I would accept the surgeon being mean now more than I would have accepted it before, now that I’ve been exposed to it…”. Teddy further observed a change from thinking all doctors had to be nice, to recognising that there was a balance of being firm, getting the work load done and communicating with others,

I suppose like a degree of firmness is still required when you’re in a senior position, like when you’re a Registrar and you try and get the work done, you still need a degree of authority to make sure the work gets done. Whereas, like before I just thought you all have to be nice.

As illustrated above, most of the medical students gave qualifications to the abrasive behaviours, however a few participants felt that this was a result of a positive process, rather than an insidious, or unseen enculturation agenda. They spoke of being desensitised as an almost necessary development, one that gave an increased understanding of the demands of the doctors. However, as explored in Chapter Three, Lempp and Seale might consider that this is, the result of the six learning processes embedded or hidden in medical training (Lempp & Seale, 2004). Basil shared this insight on the enculturation process,

Being desensitised, understanding it more, so you know that people are stressed, not that they hate you or…they probably don’t even know who you are.

Looking the part

When discussing how they fitted into the medical profession many of the participants also mentioned how important they felt professional image was, particularly in relation to how kindly or harshly, other doctors judged the medical students personal value and medical competence. Exhibiting knowledge or maintaining the image of confidence and wisdom is something that most of the participants mentioned, which would similarly

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contribute to their image of professional competence. Several participants spoke of what one needed to do in order to look like the ‘perfect’ medical student, and to fit in professionally. This included a variety of behaviours, inclusive of ‘going with the flow’, acknowledging the authority of senior doctors, and for one student, even choice of facial expression. Participants suggested that showing respect to those higher up the professional hierarchy was important for their career, and often the best way to demonstrate a doctor’s superior status was in the use of deferential language. Use of formal professional titles was seen by many of the medical students as a clear signal of their expected subservience. While patterns of communication amongst doctors is explored in Chapter Three, one physician led investigation reported that due to the lack of ‘evidence-based’ guidelines, current use of emails amongst doctors is unregulated and too casual, they recommended “maintaining a high degree of formality when using emails” amongst colleagues (Malka, 2015, p. 27). Ashley suggested that “As medical students we have to say ‘Dr’ and then their last name, we are not allowed to address them, at least at first, by their first name, cos that’s seen as unprofessional, and a bit…you need to put them up on a pedestal a little bit”. Matilda shared,

If you want to get ahead in the profession you have to make a good impression on those above you, particularly if you’re trying to get into the very competitive specialities. You have to impress your superiors, you have to be publishing in the area, you really have to over-extend yourself, otherwise you’re considered not ambitious.

Further to Matilda’s remarks on the importance of making a good impression to ones professional superiors are Chuck’s insights on the matter,

Certainly once you get into medicine it’s a lot less of how your marks are, and more of who you know, your references…you certainly see it, brown nosing so to speak…

Many of the participants shared their understandings on what they should, or should not do. The importance of blending in, not being seen as different, or a threat to the status quo was reported by several of the medical students. ‘Going with the flow’, and following established cultural norms were perceived as central to being accepted by more senior doctors. Below, three students shared their insights:

I guess we generally try and maintain a peaceful, harmonious environment and you don’t want to be seen as rocking the boat, you don’t want to be seen as being too touchy feely, or too reserved or too politically correct. – Amelia

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Amelia expanded on her observation, “I think there’s kind of that expectation that you just take it as a tongue in cheek remark and you just go along with the flow and you kind of adjust to other people’s attitude”. Chuck shared his thought that complying with the established professional and using formal titles in communication with higher ranked doctors was appropriate and respectful,

When I witness a medical student turning up in skinny jeans and a tee shirt or something talking to a doctor who is wearing a suit and tie, and like, “hi how are you going’, I cringe a little bit, so I just think that’s disrespectful.

Christine said,

I feel very much how people perceive me is sort of how I project myself, so if I am confident and keen and seem to know what I’m doing, I feel that generally I’m treated respectfully and appropriately.

The word, ‘perfect’ was mentioned by a few of the medical students in relation to the notion of professional pressure, and Ashley remarked,

I just get, like really nervous cos I feel like they are very critical of students, and especially at this point, like we’re trying to get references, and that kind of thing, so…it’s just lots of pressure on us at the moment to be like, perfect students.

There were also a few participants who shared their sense of being judged for characteristics or personal attributes that were considered to not fit within ascribed professional cultural norms or values for medical students. Lily illustrates this in the following quote,

I kind of ummm and ahhh about a question and then make a face, and one of the anaesthetists said, like this was in surgery, said ‘you should just have a neutral face when you’re thinking’, and I was like ‘oh ok. I didn’t even realise I was making a face.

A couple of the participants spoke about visual and behavioural identifiers of professionally powerful doctors. Participants suggested, that often the doctors with the greatest amount of professional and organisational power sat outside the expected bell- curve of image and behaviour. It might be argued that this is because their conduct is “protected by an established hierarchy of authority” (Brainard & Brislen, 2007, p. 1010), it also reinforced the idea that those in power can get away with conduct in a manner that less powerful doctors cannot. Lily shared:

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Consultants definitely carry themselves in a certain way. Like you look at someone and you know that they are a consultant. The way they dress, they’re impeccably dressed, but even then, someone who is really casually dressed can be a consultant. You can find them at either extremes and in the middle is the rest of us…doing what we think we’re meant to be doing.

Even though participants had shared their perceptions around how time poor, and pressured all hospital doctors were, a number of them picked up on the fact that consultants seemed immune to that particular pressure. Teddy remarked, “I suppose the seniors are not really accountable like for turning up late or not even turning up”. Lily also said, “…usually it’s because they’ve come in later than everybody else so the last person in is usually a Consultant”. A few participants had noted that communication between specialist consultants was often hallmarked by matched, and at times unwavering displays of authority, Ashley shared, “Consultant-consultant ‘communication’, it tends to be ‘I’m right, you’re wrong, and it’s just the fact of proving that”.

Cultural silos

All participants mentioned the presence of established cultures within hospitals, medical schools and the medical profession. Most of the participants spoke of ‘culture’ in terms of a silo of behaviours or norms, which could co-exist either within or side by side another separate culture. The four distinct silos of culture that participants cited, included hospital, specialty, unit and professional silos. Although the silos were grouped in environmental contexts, these cultures were considered to be driven by individual doctors, with specific reputations for bullying behaviours, It may be that the specific doctor has that sort of reputation. – Sally There were also a few unique factors within the dialogue on hospital culture that a number of participants noted. These factors included the impact of geographical location on hospital culture, namely whether the hospital was based in a rural or metropolitan setting. Furthermore, current organisational culture was perceived as impacted by whether the hospital was privately or publicly funded, as well as the hospital’s past cultural history. Participants tended to report that hospitals, which were located in rural areas, had a less rigid hierarchy, which was seen as a positive attribute. On the difference between regional and metropolitan hospitals’ cultural silos, Lily shared:

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I’ve been to a number of different hospitals this year, and I guess I did find somewhere like the regional hospitals had a great sense of community…so you get a lot of the really nice camaraderie, which is really lovely to be in. As you get to more metro hospitals, I find that that camaraderie is kind of restricted to your ward and doesn’t spill over… unless you know the people.

Mathalda also shared her insights on the different cultures between metropolitan and country hospitals,

I know there is a big difference between city an country (hospitals). I think in the country because there is such as small group of medically trained staff, they kind of hang around together as well and they are more friends rather than just work colleagues…so it’s not unusual for a medical student to be playing basketball with a consultant or registrar.

Teddy gave details of different hospital cultures she had experienced on placements,

B. is considered larger than S. It’s sort of like regional and it’s sort of the same size as the N. Hospital, it’s quite big. S. is like a truly country hospital, and I think there’s definitely a culture in terms of how you treat the juniors and the seniors.

The medical students had very firm ideas around which hospitals had reputations for being traditional, for bullying or for being culturally progressive. Size of the hospital was perceived as influencing the culture of hospitals, as was the funding source. Participants viewed those hospitals, which had a less defined organisational and professional hierarchy, more favourably. The views on the cultural silos on certain Melbourne metropolitan hospitals, are shared by Lily,

There are certain hospitals that already have that culture known to other people. Like for me there are certain hospitals, like if I went there I would have to be really really respectful of all my senior consultants and of all the senior ‘regs’, and that would be quite strict. You’d be cautious.

Dr Nick Riviera confirmed what other participants also shared; that the more informal the hierarchy, or flat the organisational structure, the more harmonious the interactions were amongst the doctors “…other hospitals like The ‘N’ or the ‘X’ they have reputations for being very laid back, everybody is happy, gets along well. There is less of a defined hierarchy”. Abigail also reported,

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I’m going to name hospitals. I actually think it’s a huge, hugely relevant thing. The culture at the A. hospital is enormously different to E. and M hospitals…I was speaking to a friend before at The A. Hospital where bullying is rife. At F. Hospital not so much.

When asked if Dr Nick Riviera had witnessed or experienced an abrasive interaction at the hospital, he said “I can probably explain that by saying I’m based at ‘X’ hospital. We have a reputation for being… ‘interesting’”. The hospital had indeed developed a reputation for violent incidents, however this was not limited to incidents amongst staff, but the hospital also had regular media coverage on extreme violence perpetrated from patients to doctors. Dr Nick Riviera continued:

It’s (workplace culture) very hospital specific. In Melbourne alone, certain hospitals have a reputation for being…much more open and friendly, other health services have a reputation for being dog-eat-dog.

Christine shared her experience of a particularly affirming hospital culture, “The ‘A. Hospital’, the culture there is generally quite a positive one. Everyone seems to be really happy there…”. Rhianna also commented,

At the largest hospitals they weren’t really…it’s hard to find a team where they will really know each other well, it’s more colleagues. The smaller hospitals… ‘S.’ is smaller and we’ll sit there with the Interns and the Regs and we’ll just have lunch together…

Chuck disclosed his thoughts on the differences between public and private hospitals,

I think it is different, public to private. Certainly private, every man is an island sort of thing, so you work individually and refer individually whereas in hospital you’re part of a medical team…

Many of the participants also shared accounts of the particular culture within a medical specialty, team or unit silos. According to participants, the culture or ‘behavioural tone’ of team silos often appeared to be set by key individuals. Positive units or teams were hallmarked by inclusion, and respect, and those units or specialties, which were considered unpleasant, were characterised by stress, fear and being ignored. Basil shared her experience,

Now I’m on paediatrics, so now it’s skewed, very very nice and respectful. Happy, affirming, positive…last year sometimes they were stressful, sometimes they completely ignored us. Generally it depended on the team.

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For medical students, Christine said whether the experience was positive or negative all came down to the inclusiveness of the unit you were placed in, “It depends what unit you’re in…other units sort of just ignore you or find you annoying”. Matilda also shared her insights,

Paediatrics, at least in M., I did find to be a very friendly team, so I think compared to say a surgical, medical unit…it’s probably not quite as strict and I am able to have conversations directly with consultants, where perhaps elsewhere like in R. I probably wouldn’t dare open my mouth.

Ashley remarked on the unit culture of her current placement,

Well at the moment it’s actually been, it’s quite relaxed. Ummm, I’m just in a team environment where, I’m playing intern…and thankfully the consultants that I’m interacting with at the moment are actually really good as well. I can call them by their first names and that sort of thing, which is really good.

Often characterised by rigid hierarchy, or abrasive behaviours, certain specialties were nominated repeatedly by the participants as having an unpleasant culture. As with the other themes, often, speciality and cultural silos were conceptualised in terms of individual influence. Surgery was a specialty that had one of the more unfavourable reputations amongst the medical students. Mathalda shared,

Maybe just the types of people, the personalities that go into general practice are maybe a lot different to the ones that choose to go into neurosurgery or cardiothoracic surgery, they’re the ones that sort of have culture of issues…

Mathalda further disclosed,

My (surgical) team that I am working with at the moment is probably the most hierarchical team I’ve probably come across so far.

Steve’s observation of surgery and surgeons poor reputation, was less about the culture of the specialty, and more about the tasks they performed, “Surgeons always cop a bad rap because they’re surgeons, they just like to cut things, physicians cop a bad rap, because they just take too long…”. Lily suggested in terms of the individual reputation of some senior doctors, “It’s like one of the main things you ask when you’re getting a hand over, like ‘who do I need to look out for’? It’s usually like when I’m starting a surgery rotation, and it’s funny

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people will go out of their way to name the nice people…and then the mean people as well”. Christine illuminated what contributed to the culture of certain specialties, by introducing the concept of norms; what was acceptable in one specialty was not necessarily tolerated in another,

I had my first rotation on surgery and then medicine, they were different environments and different things were acceptable in medicine and that’s just the culture of the subsets.

Ashley shared that, “Just being in this little cocoon of being in the Metabolic Unit. Whereas, I suppose the other Consultant, that kind of thing it’s just very, like very scary”, while Steve suggested that each specialty was a highly defined tribe, and that there was not necessarily a lot of professional respect for each other’s team:

There is certainly at our hospital a lot of tribes. Emergency tribe, physician tribe, radiology tribe, and it is, when you talk to them, it is quite obvious that they are very much tribes. They protect their own and hate on each other.

Participant discussion around the culture of the medical profession tended to focus on the individualistic nature of medicine and the psychological characteristics of the medical profession, as well as the profession’s culture of minimal work-life balance. Some of the participants shared what they considered as common characteristics of doctors, such as intelligence, high education levels, and certain personality traits, which contributed to the professional culture. Abigail said, “There’s a lot of very ‘A’ type personalities who are very ambitious, really want to be the best-of-the-best…”. Like a number of other participants, Ashley nominated personality characteristics as a reason for certain behaviours, “I don’t know if it’s just the personalities in medicine, like a lot of obsessive compulsive things…”. Amelia also disclosed,

Normally they are very intelligent (doctors) and medical students have had loads of opportunities in life, and are pretty intelligent and educated and are going to be leaders…

Hadley pointed out that the profession had a culture typified by boundaries, limits and sense of exclusivity,

I find that everybody’s a little bit quiet and reserved and not really willing to share and ummm there are so many boundaries in medicine…the doctors are always off on their own not interacting with each other or with anybody else.

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Matilda commented on aspects, which she considered unique to the medical profession’s culture. In particular the idea that the profession becomes an all- encompassing feature of your identity:

I think medicine does have its own unique kind of culture. I think there’s very much still a culture that you work yourself to the bone and I think, I mean I don’t know whether it comes from the people who self select into medicine but I still think there’s a real culture that you know, medicine is your life…

Whilst participants did not overtly discuss the culture of medical school faculties, a couple of female medical students were particularly scathing of what they perceived to be illogically inflexible teaching environments. The comments below illustrated some of their concerns around bullying and university processes, attitudes and values. Having a significant mental health condition initially elicited by the bullying she endured on placement, Ashley was then told that she must go back to the placement where it had occurred. Even though the university was aware of her mental health condition, due to her concerns about reporting the bullying, Ashley had chosen not to give the university any details of the incidents:

I actually was failed in my fourth year of uni, I failed one unit because of ‘poor attendance’. The minimum is 80% and I had 78%, and the reason for the attendance was due to mental health conditions…I ended up having to put everything on hold for a year and I had to go back… I had to go back… and it was just the same sort of thing…

Ashley elaborated,

I’ve talked to psychiatrist about it (the bullying incident) but I’ve never mentioned it to uni, because I feel like it’s just…they’re not going to help me. Really they expect you to just ride through it. There was a lot of potential for flexibility, to make it work for both of us, and they just didn’t.

Hadley also shared,

I guess I have pushed boundaries a few times in my short medical degree so far because I’ve had children and have had to take time off…I worry personally that me pushing boundaries, and suggesting that the university is being discriminatory for example will effect my future…

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8.7. Chapter summary

Chapter Eight focused on the directly experienced or witnessed incidents of bullying and harassing behaviours. The themes explored in this chapter included the interactions between hospital-based doctors, including described patterns of communication amongst the doctors. Abrasive incidents whilst teaching were commonly reported by most of the medical students. Most of the participants described the impact of abrasive incidences in individualistic terms, and as negative in nature. Furthermore participants discussed the contexts within which the behaviours occurred. Many of the medical students described the medical profession, its enculturation processes, its positive attributes and especially the importance of image (including the impression of academic competence) for those who practice medicine. Interestingly the insights shared by participants on the context of bullying behaviours, still focused on individual influences. Most of the participants spoke of the pervasiveness of unique cultural environments, and broke them down into silos of unit, specialty, organisation and profession. Chapter Nine will now consider the emergent themes, and examine them in the light of existing literature. Furthermore, Chapter Nine will also explore participant beliefs, behaviours and context, underpinned by principles of oppression, as well as the limitations and strengths of the research.

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Chapter 9. Discussion

This thesis sought to examine how medical students’ conceptualised bullying amongst hospital-based doctors. Therefore this chapter provides a detailed exploration of the key themes, which have emerged from consolidation of the study findings and the literature considered in Chapters One to Four. As with the findings, the discussion is broken into the three principle concepts of beliefs, behaviours and context. Moreover, it is anticipated that the unpacking and examination of emergent themes, will contribute to the research aim, which is to gain an enhanced understanding of medical students’ perceptions and experiences of workplace bullying amongst hospital-based doctors. The research itself was underpinned by a framework of power dynamics and oppression, as well as an increasing body of existing knowledge on abrasive, bullying behaviours amongst doctors.

9.1 Beliefs on bullying behaviours in the practice of medicine

How do some medical students’ perceive bullying amongst hospital-based doctors? All of the medical students interviewed believed that they were situated at the bottom of the hierarchical ladder both organisationally and professionally. Furthermore they believed others viewed them as low in the hierarchies. This awareness of low hierarchical status is not new, and is congruent with other relevant Australian and international studies, as previously discussed in Chapters Two and Three (Paice, Rutter, Wetherall, Winder & McCanus, 2002; Scott, Blanshard & Child, 2008; Mitchell et al., 2011; Rees & Monrouxe, 2011; Fnais et al., 2014; Gan & Snell, 2014). This finding (that these medical students saw themselves as at the bottom of a rigid professional and organisational hierarchy), combined with their strong self-perception as powerless and vulnerable to power abuse, may well influence their insights around the inevitability of bullying and sexist behaviours perpetrated by senior doctors. Similarly, these perceptions may have influenced their insights into the nature of cause or blame, the character of the impact, and the possibility of potential career retaliation for reporting the abrasive behaviours. The medical students’ vulnerability and disempowerment from the (self- identified) bottom of the medical professional and organisational hierarchy, was likely felt keenly given the increased competition in an already demonstrably competitive

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profession. Moreover, it has recently been suggested that most trainee doctors are employed on 12-month only, and that within the Australian context, there has been an almost doubling of medical student graduates since 2002 (Veness, 2017). This sense of vulnerability and powerlessness, or expendability, is reflected in multiple studies (Timm, 2014; Rees & Monrouxe, 2011; Gan & Snell, 2014), with the recent AMSA parliamentary submission reporting on bullying and harassment in medicine, encapsulating many medical students’ sense of “inferiority and disempowerment” (AMSA, 2015, p. 4.). On a broad level workplace-bullying researchers suggest that when it comes to bullying, hierarchy, in any profession or institution, is an important, some might claim, vital, factor in its definition, perpetration and perpetuation (Hoel, Sheehan, Cooper & Einarsen, 2011). Focusing on medicine, there are particular structures, processes and cultures within the hospitals, and the medical profession alike, which influence elements of a medical students perception and experience of bullying. Within a medical organisation, hierarchy is one example of such a structure that influences both the processes and the culture within (Holm, 2006; St-Pierre, 2012). In turn this structure, its processes and culture, has the potential to influence the medical students’ perceptions and experiences. This multi-faceted factor is sometimes hypothesised as a contributing factor in workplace bullying studies, organisational policies and professional body regulations detailing abrasive interactions in medicine (Sweet, 2005; Scott, et al., 2008; Shabazz, Parry-Smith, Oates, Henderson & Mountfield, 2016). As mentioned earlier, in one of the comparable studies, which explores medical student perception of factors contributing to ‘abuse’, student narratives also nominated hierarchy as a perceived cause (Rees & Monrouxe, 2011). It is perhaps unsurprising then, that the majority of participants mention the concept of hierarchy as an implicit correlation to bullying behaviours amongst doctors in a hospital context. While participants in the study nominated ‘hierarchy’ as a potential correlation to the bullying behaviours, there was no analysis of what the term ‘hierarchy’ meant on a broader, contextual scale, beyond recognition that as medical students they felt unable to implement changes, or complain against the behaviours. The word powerlessness, oppression, or marginalised, were never used by participants in the study in relation to perceptions or experiences, and certainly not in relation to a understanding of hierarchy as a structure, or process. However, while participants used phrases, such as ‘power difference’, ‘positions’, ‘positions of power’, ‘power trip’, even

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‘power disparity’, they were typically applied to an individual. Furthermore, the word ‘powerless’ was not used by participants in this study in relation to a broader environmental understanding of hierarchy. Most of the medical students identified abrasive behaviours, bullying, or harassment, as an expected, or inevitable part of medical training. The majority of medical student participants felt that because the current cohort of senior doctors were subjected to bullying when they were juniors, that they felt vindicated in treating medical students in the same way. Many students believed that abrasive, bullying teaching styles was a perfect illustration of intergenerational legacy of, ‘this is how I was taught so I will teach you using the same method’. This perception of historic, intergenerational bullying corresponds with other studies and editorial commentary, which span over a period of decades (Bourgeois et al., 1993; Kassebaum & Cutler, 1998; Scott, Caldwell, Barnes & Barrett, 2015; Timm, 2014). While many of these studies contain an analysis of the enculturation process, the cycle of abuse and its likely influence of bullying behaviours, there is currently no known study that captures medical students’ perception or sense of certitude regarding the abuse. This research is the first known investigation to share such narratives. Much of the medical students’ perceptions around intergenerational legacy and inevitability of bullying behaviours, when overlaid with elements of contextual oppression, may generate a new understanding of intergenerational bullying. Participants reported a sense of inevitability and enormity of the problem, suggestive of a powerlessness stemming from “lack of decision-making power in one’s working life, and exposure to disrespectful treatment because of the status one occupies” (Mullaly, 2010, p. 57). While components of an oppressive contextual framework are captured in the Job Demand-Control-Support (JD-C-S) model and sometimes applied to workplace bullying (Tuckey, Dollard, Hosking & Winefield, 2009; Rodwell & Demir, 2012b), it is significant that to date broader models of oppression have not being applied to understandings (medical student or otherwise) of bullying amongst hospital-based doctors. As social work scholar Mullaly suggests, “when people perceive their situation as natural and inevitable, and there is an illusion of freedom and opportunity, no other weapons are necessary to defend and legitimate unjust ways of life that benefit the privileged groups at the expense of the oppressed group” (Mullaly, 2002, p. 40). Using the same notion of intergenerational legacy, most participants were hopeful of positive change within the medical profession, with new student cohorts

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having the potential to bring new perspectives on abrasive behaviours amongst doctors. However, other participants were less certain about a positive future for medical culture. There is little research that explores medical students’ own sense of hope, however literature addressing medical student and junior doctors perceptions or opinions on the issue, report a definite need for change in perceived and reported levels of bullying behaviours (Cheema, Ahmad, Naqvi, Giri & Kallaperumal, 2005; Timm, 2014; AMSA, 2015; RACS, 2015b). The stated need for a significant change within medicine, and the above-identified gap in knowledge, indicates an area that may be ripe for future research. A few research participants felt that if senior doctors remembered how they felt when they were once medical students that this could help ameliorate the current culture of tolerance towards bullying and abrasive behaviours. While this is not a concept that is discussed in other relevant literature, viewing the insight through a lens of contextual oppression and power dynamic, it dovetails with the concept that by othering, or distancing medical students and junior doctors into a distinct, marginalised and separate group, the more powerful dominant group of senior doctors can maintain their own professional and organisational status quo. Similarly, in the study by Gan and Snell, participants reported feeling unvalued and disrespected in their position of medical student (Gan & Snell, 2014). There were a variety of perceptions around why bullying occurred amongst hospital-based doctors. Consistent with other relatable studies, it was observed that many of the participants focused on individual variables rather than context or environmental elements as the initial cause of bullying (Stebbing et al., 2004; Martin, 2008; Scott et al., 2015). Within this study, many students implicated the victims, or targets, as well as the bully as the reason for the abrasive behaviours. To date, there appears to be no known studies that specifically explore medical students’ perceptions of cause or correlation of bullying behaviours amongst hospital-based doctors. Within the Australian context, the increase in public awareness around the discourse on abrasive behaviours, junior doctors and medicine may increase the future proliferation of studies on the topic of cause, correlation, and perceptions. However, currently the only published relatable studies explore medical student perception on meaning of mistreatment, with an additional study by Rees and Monrouxe the only one investigating factors nominated by medical students as contributions to ‘abuse’ (Rees & Monrouxe, 2011). Some participants felt that as an expected part of the hospital

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workplace and medical professional culture, initial bullying behaviours were allowed to continue unchecked. Both these notions are not new, and are congruent with other studies. However, this study is the first known to capture the perception that bullying is such an expected part of medicine, that it can impact a medical students willingness to object or resist, or report the behaviour. A couple of the participants perceived that broader environmental influences might cause or were correlated to bullying. These elements included hospital management allowing the behaviours, and aspects of the medical profession itself that contribute to bullying interactions amongst doctors. These nominated elements are congruent with other research findings. Additionally, a few participants perceived that the permissive culture inherent in medicine and particularly some medical specialties contributed to bullying behaviours. This is consistent with other publications and studies (Owler, 2015; RACS, 2015a; RACS, 2015b). Notably while some workplace- bullying researchers nominate oppressive or restrictive elements as significant antecedents to bullying, not one of the medical students interviewed used the term ‘oppressive’ for any of the perceived contributory structures, processes or culture. Applying concepts of oppression may help generate a new understanding of why bullying continues to occur amongst hospital-based doctors. Most of the female participants raised theories relating to high prevalence and why sexism and sexual harassment was still so pervasive in medicine. These theories included an intergenerational influence and a fear of retribution if reported, and the influence of media on perpetuating the negative impact if women doctors speak out about the behaviours. Both perceived and documented pervasiveness of sexism and sexual harassment is consistent with other current research, however influence of media on medical student perceptions has not been researched or written up in any detail. The hypothetical in this research project identified medical students’ perceptions of bullying prevalence and definition. Most participants believed that bullying is not uncommon amongst hospital-based medical doctors, which is consistent with research results on reported prevalence levels. However, even though the behaviours described in the hypothetical fulfilled the operationalised definition of bullying, that is, the definition you might find in a hospital’s human resource strategy or a code of conduct; not all the participants identified and labelled the senior doctors’ behaviour in the hypothetical case scenario as bullying. Also a number of participants reported a generalised uncertainty around labelling abrasive behaviours as bullying, with some participants asking was the

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behaviours just what hierarchy ‘looked like’, or was it simply teaching or mentoring styles? All of the research participants reported a number of different criteria that they used to determine if the behaviour was bullying. Some of the criteria such as having a negative impact on the target, power disparity between the target and the bullier, and a behaviour being repeated, were consistent with other relatable studies. However, many of the participants used alternative criteria to conceptualise whether an interaction was bullying or something else, such as whether the bullying incident happened privately or publicly, thereby increasing the apparent level of embarrassment or shame felt by the target. The intentions of the bullier, during the abrasive interaction, and the presence or absence of an apology, were also important factors for the medical students in labelling behaviours as bullying. As mentioned, this finding is consistent with the Gan and Snell study which found that medical students were sensitive to the apparent intent of their faculty teachers when it came to incidents of mistreatment (Gan & Snell, 2014). However, while there was one generalised workplace bullying study (Saunders, Huynh & Goodman-Delahunty, 2007) that outlined differences between criteria used in formalised definitions of workplace bullying, and ‘lay’ definitions, the above factors were generally not consistent with definitions of workplace bullying found in other literature and research related to bullying amongst doctors, or in policy, regulations or legislation. The findings do correspond with other past and current research suggesting that medical students are subject, and witness to, abrasive behaviours by senior doctors, which are often labelled as mistreatment, or abuse, or humiliation. In an Australian context, it is only within the last 24 months that the term bullying has routinely been used in publications and investigations related to bullying amongst doctors. It may be that the participants’ use of different definitional criteria, and their labelling of bullying behaviour as something else, was influenced by the historic use of the terms ‘mistreatment’, or ‘abuse’, alternatively, overlaid with Young’s model of oppression, it might flag a process of subjugation. While the majority of interviewed medical students felt that abrasive behaviours, and bullying interactions are fairly prevalent amongst doctors, there were a few students who felt that the behaviour is more often than not something less serious, a senior doctor trying to teach, an overuse of the term bullying, a miscommunication, a misunderstanding or just a bad review from a disgruntled trainee doctor. While a couple of survey studies suggest that some medical students don’t report abrasive behaviours

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because they do not consider it serious enough, this is not something which is necessarily raised in great detail nor expanded upon in other studies. Congruent with other studies, which were explored in Chapters Two and Three, many of the medical students perceived that bullying behaviours had a negative impact on the individuals targeted, and for those witnessing them. However, participants also nominated that the outcome could also be positive or the negative impact relatively minor, or the abrasive behaviours were ‘victimless’ in nature. No medical students in this investigation shared their understandings around the impact of bullying on a broader scale, such as community, the profession as a whole, or the organisation. That the focus for most medical students was on the individual contribution and impact of bullying was not inconsistent with other relatable studies. One study reported being struck that the vast majority of the 200 medical students interviewed nominated individual factors in both their contributing factors to the bullying, and their response to the behaviour (Rees & Monrouxe, 2011). Additionally, learning that medical students sometimes conceptualised bullying behaviours as acceptable, or even positive, has both potential implications for further research and extending current knowledge on medical student perceptions and experiences of bullying. Medical students believed that by formally reporting abrasive, bullying behaviours, this action had the potential for a significant negative impact on their day- to-day professional functioning, and their long-term career. This is not new knowledge, however, when overlaid with a framework of oppression, including personal, cultural and structural oppression, any new insights formed may have implications for development of effective management or prevention strategies (Fnais et al., 2014). Many of the participants interviewed in the research felt there was a better alternative to current hostile or bullying interactions, and some offered strategies. That there must be a better alternative is often implied in other relatable research, but most often the findings stop short of getting participants to offer those suggestions. A number of the participant beliefs can be elucidated and extended by applying aspects of Young’s ‘Five Faces of Oppression’. The concept of the five faces includes the oppressive elements of powerlessness, marginalisation, exploitation, violence and cultural domination (Young, 1990). The application of themes of oppression to the matter of bullying amongst medical doctors has not been documented before, and this has the potential to generate new understandings of medical student perceptions and experiences of bullying amongst hospital-based doctors. Re-conceptualising the issue of

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bullying amongst doctors, through a lens of power abuse and oppression, may facilitate the medical profession to address the issue of , in a manner that is consistent with the current broader Australian context. Initially when participants spoke of their views and conceptualisations of hierarchy, it was around their being at the bottom of it, both organisationally and professionally. Medical students also felt that hierarchy in some way contributed or enabled bullying, harassment or abrasive behaviours. As previously mentioned, while most of the medical students alluded to hierarchy in some, almost abstract form, that none of them used the word ‘oppression’ or ‘powerlessness’ flags the possibility that they may not have the language to conceptualise and articulate the restrictive mechanisms within a hierarchy. Just as workplace bullying experts suggest that contextual aspects of an organisation can precipitate bullying (Salin, 2003; Caponecchia & Wyatt, 2011); both organisational and professional hierarchy can be viewed as structures, capable of enabling oppressive workplace practices, including bullying behaviours. For medical students, trainee doctors, and qualified physicians alike, mechanisms of professional and organisational hierarchy can give or restrict freedoms of behaviours and access to resources, and can conversely also contribute to a person being vulnerable to behaviours which marginalise, exploit or are representatively violent, such as bullying, or harassment. Often those at the bottom of an organisational or professional hierarchy are powerless to make significant changes to stop oppressive practices, with actual policies and processes embedded in organisations and institutions legitimising the powerful group at the expense of the outranked group (Young, 1990; Mullaly, 2010). Furthermore, all the participants in this study, and in others studies, unequivocally articulate their subordinate hierarchical status, flagging the possibility that they are defining themselves through the eyes of the culturally dominant group. By overlaying the oppressive element of cultural dominance and the associated psychological factor of internalised oppression, with the research finding that some medical students identify bullying behaviours as non-problematic or even positive, a new level of understanding is revealed on the subject. The group who are culturally dominant sets the accepted values and norms of the medical profession, and within the hospitals. The interview data demonstrated that medical students not only reported that professionally and organisationally powerful doctors modelled that bullying behaviours were acceptable, either by their perpetration or tolerance of it, but that they also gave

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weight to the views, values and behaviours of the dominant group, irrespective of how cruel, humiliating or abrasive it was (Mullaly, 2010). In identifying and acknowledging that much of the research on mistreatment, abuse or bullying of medical students and doctors focuses on the individual, not on broader or contextual factors of correlation, cause or impact of bullying, our existing understanding of medical student perceptions of workplace bullying has grown. It emerges that, for some medical students, the conceptualisation of what constitutes bullying behaviours, and why it continues to exist, is limited in focus. This new recognition provides an opportunity to help medical students, and trainee doctors develop a broader understanding of the issues, and develop language and strategies that are targeted and effective in managing or preventing workplace bullying. Moreover, that the medical students used criteria other than operationalised measures to define bullying behaviours, and that they perceive bullying behaviours as something other than what it is, may indicate that their ability to conceptualise and define bullying behaviours is being influenced by the culturally dominant group. That some medical students use additional, alternative criteria to help them define bullying amongst doctors, provides new insight. That their conceptualisations may be influenced by elements of oppression further expands that understanding. In light of the findings related to medical student conceptualisations of bullying, it is feasible to suggest a widening of the definitions and characterisations that are found in current health practices and policies. One such strategy might be to develop a continuum, or model of bullying behaviours, to help identify and modify abrasive conduct.

9.2 The good, the bad and the ugly: behaviours experienced by medical students

This research also sought to explore how some medical students experienced bullying behaviours amongst hospital-based doctors through examining a second question: What are some medical students’ experiences of bullying amongst hospital-based doctors? Themes developed from the data collected, include incidents that the participants reported as being directly involved in, either as a bystander or as a target. However, the bullying or abrasive interactions which the participants did report experiencing, generally fell into two categories, overt or covert bullying. The vast majority of interviewees reported having first-hand experience with abrasive behaviours

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amongst hospital-based doctors. This is consistent with other local and international studies, some of which were examined in the first chapter of the thesis. Additionally most of the abrasive conduct reported by participants was covert in nature. Ignoring, passive aggression, or surreptitious undermining of professional capacity were all behaviours reported by the medical students. While this knowledge is also broadly consistent with another study (Rees & Monrouxe, 2011), the extent of prevalence, and the impact of ignoring or exclusionary behaviours by senior doctors, was particularly notable in this study. To date this characteristic of bullying amongst hospital-based doctors has not been thoroughly or exclusively investigated. This indicates an area, which may be valuable for further investigation. Experiences of academic humiliation were shared by a majority of the medical students, with most participants reporting that they had witnessed or been at the receiving end of aggressive questioning by senior doctors. In most of these interactions, participants consider the learning component negligible at best, and at worst an opportunity for senior staff to shame or humiliate medical students. This corresponds with the results of current research on academic humiliation (Fnais et al., 2014; Scott et al., 2015). However, there were also several participants who shared that while the experiences were humiliating, the communication may have been said with positive intent, or even possibly produced a constructive outcome in the long term. As illustrated in the findings chapters, one medical student shared how they reframed a humiliating abrasive interaction from being hurtful and shameful, to conceptualising it as a positive, learning experience. These insights on being academically humiliated are generally consistent with results from other relatable research (Gan & Snell, 2014; Scott et al., 2015). In this study, with the exception of one incident where both clinicians were consultants, the doctors who perpetrated the overt abrasive behaviours were professionally or organisationally senior to the targets. This matches with the results from relatable studies (Bourgeois et al., 1993; Fnais et al., 2014; Timm, 2014; RACS, 2015b). Like the perceptions of cause and impact, the actual reported impact of these overt bullying behaviours were focused only on consequences for the individual doctor or trainee who was directly involved, and in some instances, bystanders and patients. Most participants shared insights on individual negative emotional, psychological or physical consequences of the experienced bullying behaviours. None of the participants reported negative collective impacts on the profession as a whole, or the organisation in

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which it took place. As previously flagged, this individualistic focus on reported impact was also noted in one other relatable study (Gan & Snell, 2014). While it might be speculated that the broader cultural context in which the other investigations had been conducted could influence either a collectivist or individualistic focus by medical students and trainee doctors, remarkably the study results remain similar across a diverse range of both Western and Eastern cultural settings. The focus on the individual may be influenced by a number of factors, not least that historically the discourse on abrasive behaviours in medicine has often concentrated on individual elements, however, by applying aspects of contextual power and oppression to the data on experiences of overt abrasive behaviours, we may stand to gain new knowledge. While all the participants reported having witnessed or been part of abrasive, bullying behaviours, most of the medical students interviewed also shared that they had directly experienced positive interactions between themselves and senior doctors, as well as between other hospital-based doctors. The common thread in most of these reported positive interactions was an element of mutual respect and inclusion. Positive interactions were something that has generally been underreported in other related research, typically when the focus is often on the negative interactions, with those abrasive behaviours frequently not being situated within a broader interactive context. Questions arise such as whether there was scope in the other studies for medical students to comment or share the continuum of behaviours and interactions, and if there was, perhaps it simply wasn’t reported in the resultant literature. However, perhaps there was no opportunity for participants to contextualise their bullying events within everyday interactions? Some participants mentioned the benefits of having a positive professional mentor, who allows them to develop constructive, less abrasive interaction styles. The significant influence of mentors within medicine is not new knowledge, but if layered with principles of oppression and power dynamics, it indicates an area with potential to either perpetuate oppressive processes and culture, or provide leadership in changing the current context which has conceivable ability to foster or perpetuate bullying, abrasive interactions amongst doctors. Not all the behaviours that participants reported as generating a negative impact would be considered as bullying by many of the current regulations, policies and legislations. Many of the studies exploring abrasive behaviours amongst doctors and medical students provide a definition of bullying for the participants, which then

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precludes the sharing of behaviours, which fell outside the nominated definition of bullying, harassment or mistreatment. However, the results in this research regarding the disconnect between abrasive behaviours and behaviours which would be legally, or officially nominated, and those behaviours described by the participants, was consistent with participant results in the Canadian study on mistreatment and medical students in the learning environment (Gan & Snell, 2014). Gan and Snell’s research indicated that large numbers of their participants labelled experiences as mistreatment even though they sat outside the institutions own formalised definition of ‘mistreatment’. While the literature generated by the Canadian study doesn’t elaborate on the exact nature of the disconnect between incidents, it is identified within this research, with medical students having experienced the abrasive incident as a one-off event, which would not, under many institutional policies be considered workplace bullying. That there are documented inconsistencies between what medical students report as experiences of bullying, and the operationalised definitions of bullying are cause for future investigations. Communication patterns amongst hospital-based doctors were described by participants as falling into categories of unwritten, secretive codes or rules of conduct, formal versus informal patterns of communication, or duplicitous communication. Most participants mentioned the presence of unwritten rules that they, through a series of informal encounters with senior doctors, are made privy to. Although not all medical students reported being privy to the unwritten rules, with some only find out of their existence once they have transgressed them, and been reprimanded. Although there is literature that explores the covert, or hidden nature of learning medical professionalism (Lempp & Seale, 2004; Brainard & Brislen, 2007), and there is research and literature on collaborative interprofessional communication (Barker & Oandasan, 2005; Hall, 2005; Gittell, Godfrey & Thistlewaite, 2012; Thistlewaite, 2012) and individual acquisition of communication skills in medicine (Mendick, Young, Holcombe & Salmon, 2015), there is a seeming lack of research exploring the nuanced patterns of communication amongst doctors as a collective, particularly those communication modes which have been self-identified, and deal with abrasive bullying interactions. A number of participants spoke of the importance of using formal written and verbal approaches to communication, often nominating the use of formalised language when connecting with someone higher in the organisational or professional hierarchy than themselves. While the existence of a rigid organisational and professional

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hierarchy within medicine is well documented, the of that hierarchy through approaches to communication is less well investigated. However, that formalised language is used when interacting upwards in medicine is congruent with one study, which explores patterns of texting between hospital-based doctors (Wyber Khashram, Donnell & Myer-Rochow, 2013). While other significant studies on communication in medicine are explored in Chapter Two of the thesis, the investigation by Wyber revealed that electronic communication in the form of an SMS (Short Message Service) is likely to follow formalised organisational and professional hierarchical channels (Wyber et al., 2013). This thesis is the first known research product that outlines medical student insights on bullying and collective communication patterns amongst doctors. The individual nature of the behaviours explored above, the impact of the behaviours, and the patterns of communication noted, will now be explored by applying elements of Young’s Five Faces of Oppression theory. The individual focus on experienced overt and covert bullying behaviours overlaid with five elements of powerlessness, cultural dominance, marginalisation, exploitation and violence will generate expanded knowledge in the area of medical student experience of bullying behaviours amongst hospital-based doctors. While all of the medical students reported having been the target of, or having witnessed abrasive, bullying behaviours by hospital-based doctors, as discussed in Chapter Four it is recognised that there are already some documented elements of power abuse and power dynamics throughout the discourse of bullying in workplaces, healthcare and specifically medicine. Additionally, Figure 4.1 in Chapter Four provides a visual representation of how dynamics of power and oppression impact doctors’ bullying behaviours experienced and perceived by medical students. When we recognise the full extent of powerlessness inherent in a medical student’s position, for those medical students to either effect changes and make professional decisions or choices, it becomes apparent that in certain contexts, through social processes and structures, they are vulnerable to continuing oppression through the mechanisms of cultural imperialism, marginalisation, exploitation and violence. Medical students reported experiencing exclusion in a number of settings, which in turn often left them feeling redundant, or useless, and looking for ways to reduce their visibility which then served to reinforce the dominate groups’ opinions and definition of them. That the bullying behaviours experienced by medical students would

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often have an element of humiliation to them (behaviours imposed upon them simply because of their medical student status), speaks of a violence characteristic of oppressed groups (Young, 1990; Mullaly, 2010). As much as the behaviour was reported as being individually perpetrated, the violence that medical students experienced was structural as much as it was individual. Violence, such as bullying behaviours, is considered structural in nature when the perpetrators receive little or no punishment or sanction, and the behaviour was “tolerated, accepted, or found unsurprising by the dominant group” (Mullaly, 2010, p. 60). Abrasive, mistreating, or bullying behaviours are considered by many of the medical students in this study, and other studies, as an intergenerational legacy, however, when unpacked, that legacy may actually be the face of structural violence. The bullying reported as experienced by participants, was expected, and tolerated by others, and because the behaviour was never reported, the perpetrator received no known punishment. As referenced earlier, some participants from within this study shared the perception that the impact or consequence of bullying behaviours might be positive; however, a disparity between perceptions of impact and experience of impact was noted, with all but one student reporting that the experienced impact of bullying behaviours was overwhelmingly negative. Identifying that there was a difference or a disconnect between the perception and the experience, flags the possibility that there was a process or contextual climate that may impact medical student perceptions. That none of the medical students would formally report the bullying behaviours, even though the experienced individual impact was negative, speaks further to the existence of this process. Viewing this disparity or ‘space’ through the lens of oppression, one can note cultural domination, which will influence the cultural norms and values of the professional and organisation, as well as the medical students’ perceptions. The experienced individual negative impact which medical students report is the element of violence which Young outlines in her Five Faces theory, the psychological and emotional pain of which the students speak is the result of bullying behaviours, in the form of victimisation, stigmatisation, humiliation, and intimidation. As previously noted, collective patterns of communication have been recognised in this study. By applying elements of powerlessness and cultural domination it can be shown that by conveying information selectively, and covertly, that powerful doctors are applying their cultural norms and values, on a group who, due to their medical student

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status, are potentially vulnerable and powerless to ignore the information, no matter how idiosyncratic that advice may be. Additionally, the very nature of duplicitous, covert information exchanges means that some of the medical students are seemingly excluded from the information, indicating that particular medical students can be further marginalised by lack of knowledge, while simultaneously reinforcing that senior doctors have the balance of power that comes with accrued wisdom. Moreover, that medical students both within this study and others (Wyber et al., 2013) report expected formal communication in interactions with senior doctors, suggest that hierarchy is not just embedded within communication processes to senior doctors, but that the expectation to be ‘reverential’ in their language and exchanges, signals the presence of mechanisms which are determined to maintain a culture of oppression for some, and ascendency for others.

9.3. Context of bullying: The medical profession and cultural silos

This thesis also explored medical students’ insights on bullying amongst hospital-based doctors and context or setting. The third question of the thesis was: ‘How might power and oppression dynamics contribute to our understanding of medical students’ perceptions and experiences of bullying amongst hospital-based doctors?’ In answering this question, particular focus was placed on both the organisational and professional environment. An observation of participant findings on issues of context within workplace bullying amongst hospital-based doctors, was that the area did not generate the same level of discussion that medical student beliefs and experiences did. It would appear that on this topic, for medical students, broader environmental structures, process and practices were not the main focus. While the limited participant engagement in this area has dictated that a more nuanced investigation on contributing systemic aspects was beyond the scope of this thesis, it flags the possibility for further investigation. However, within this research, elements of the medical profession, as well as the existence of cultural silos were the two core areas of findings in the contextual domain. While some of the insights on the medical profession were congruent with results from other relatable studies, the participants’ perspectives on bullying and cultural silos were novel.

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The medical profession

Within the participant responses on the medical profession, there were three consistent themes, defending the profession, enculturation process, and projected image. Most of the medical students interviewed were very keen to emphasise the positives of the medical profession, and shared the feelings of camaraderie in professionally difficult times. Likewise many of the participants qualified or justified doctors’ abrasive behaviours, suggesting that the work of a doctor was often very challenging and stressful. That certain workplace tasks or situations may increase the risk of bullying occurring is consistent with other research (Hauge, Skogstad & Einarsen, 2007; Rees & Monrouxe, 2011; RACS, 2016; Victorian Auditor-General, 2016). What was also observed however was that most participants were very keen to absolve the profession from fault, with one participant suggesting that for abrasive behaviours amongst doctors were made by university staff, even before the students had gone on placement. Research participants reported a gradual, but very definite process of enculturation into the medical profession. Participants reported a shift in what they considered acceptable behaviours from the first day of medical training to where they were at the time of being interviewed, which was generally the last or second last year of training. Most of the participants felt they had become desensitised to abrasive behaviours. Other research which focuses on how medical professionalism is learnt, suggest that guiding principles such as respect, integrity, honesty, excellence and accountability are taught at the commencement of medical studies, however a number of researchers also suggest that parallel to this process is a hidden program of learning which is generally accepted, but also absent from the formalised curriculum (Bourgeois et al., 1993; Lempp & Seal, 2004; Brainard & Brislen, 2007). The early enculturation of medical students, and the embedded, often-insidious nature of the process, documented in these other studies was also consistent with some of what the participants shared. The enculturation of medical students into a bullying permissive culture is sometimes mentioned in tandem with abusive behaviours amongst doctors, although never couched in terms of being an element of oppression (Rees & Monrouxe, 2011; Timm, 2014). While this study touches on medical student insights of correlation, a detailed and transparent account of the link between enculturation and bullying intra- professional conduct has, to date, not been fully unpacked by other researchers. That

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there are limited studies, which comprehensively explore medical students’ views on professional and organisational enculturation, combined with bullying behaviours, flags an area ripe for further investigation. Many of the participants reported that the appearance of fitting in, within a hospital environment, and within medicine as a profession, was very important to them. Several of the participants spoke about needing to portray to senior doctors that they were perfect students, or that they looked professional, or that they were prepared to go with the flow of others, or that they would adhere to the rigid hierarchical structure or processes within the hospital and medical profession. Within the current discourse of bullying amongst doctors, ways that medical students try to ‘fit in’ professionally or organisationally have not previously been examined.

Cultural silos

All participants mentioned that cultural silos were well established within hospitals, medical schools and the medical profession itself. Four distinct silos of culture were noted, they were, hospital, specialty, unit and professional silos. According to participants, a hospital’s culture was influenced by geographical location, which is rural versus urban, funding source, meaning public or private hospital, and past cultural history. Participants suggested that within the hospital, specialty, team and unit, the individual doctor in charge set the cultural tone, or acceptable standard of behaviour. Within other relatable research, the fact that there are such distinct cultures is often limited to discussions around specialty impact, so surgeons, gynaecologist and obstetricians are often put forward as the specialties that are most permissive to bullying or harassing behaviours (Ogden et al., 2005; Cresswell et al., 2013; Owler, 2015). Further research aimed at gaining a broader and more nuanced understanding of cultural variability in the profession of medicine and within hospitals, may provide an enhanced understanding of medical student perception and experience of bullying amongst hospital-based doctors. A final observation on context is that the participant discussion around culture of the medical profession again tended to focus on individualistic aspects of medicine, particularly the psychological characteristics that are sometimes considered pervasive in doctors. While this proclivity for the medical students to focus on the individual is under-explored in most other relevant studies, the interest on may

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actually be influenced and perpetuated by the plethora of studies which focus on the individual doctor’s influence on the environment, a focus which is also often favoured in media representations of bullying in medicine. The individualistic focus of the medical students is noted with the findings in both the beliefs and the behaviours sections of this research. How this individualistic focus may or may not impact on medical student perception and experience of bullying amongst hospital-based doctors is an important subject for further investigation. When viewed through a lens a Young’s Five Faces of Oppression theory, that many of the medical student participants offered qualifications or caveats for the bullying behaviours of the doctors, flags the possibility that the concepts of internalised oppression and cultural domination (Mulally, 2010), may be implicated. When some of the vulnerable group members are defending and adopting the values, norms, beliefs and practices of the dominant group members, it signals an acceptance by the medical students of the negative identity bestowed on them by the dominate group (in this scenario professionally and organisationally more powerful doctors), and in turn serves to perpetuate the abrasive bullying behaviours and reinforce the dominate groups value system (Mullaly, 2010). Many of the medical students shared their need to ‘fit in’ to the existing dominant professional and organisational culture. The participants revealed how they felt a need to think and behave a certain way, physically present in a particular way, and as one medical student shared, she was even told what facial expressions she should have in certain situations. Applying the element of cultural imperialism in Young’s theory of oppression, would highlight that the vulnerable group (medical students) are aware of the dominant cultural groups (senior doctors) expectations, norms, or values, and that they are trying to comply, and reduce their resemblance of outward difference (Young, 1990; Mullaly, 2010). Furthermore, internalised oppression is sometimes characterised by members of the vulnerable group learning “to behave in ways that do not provoke retaliation or draw attention” which accurately describes the perceptions and behaviours of the medical students attempts to try and ‘fit in’ (Mullaly, 2010, p. 163).

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9.4. Implications

There are a number of implications that can be drawn from the synthesis of participant data and existing research and theory. Section 9.4 encompasses two areas where the findings may generate changes or outcomes, these include: medical education curriculum and implications for future research.

Implications for medical education

While a few students shared their thoughts on aspects of their medical school curriculum, this study has not examined current program content being taught at Victorian medical schools. Therefore any suggested implications for medical education are done not as a critique of current content, but rather as concepts, which may complement, enhance, or dovetail with the current syllabus. It is proposed that findings from this study might prompt a review of curriculum and strategy currently employed within schools of medicine. Specifically those strategies, which address the issue of medical student experience of bullying amongst hospital-based doctors. Any current medical education research or curriculum content which focus solely on individual amelioration or contribution to bullying behaviours, or aim exclusively on increasing individual resilience may be incomplete, particularly given the plethora of workplace bullying studies that implicate environmental or contextual factors (Salin, 2003; Hauge et al., 2007; Baillien, Neyens, De Witte & De Cuper, 2009; Einarsen, Hoel, Zapf & Cooper, 2011). The participant narrative on the individualistic nature of bullying, indicates that medical students have somewhat paradoxically, conceptualised the abrasive behaviours as both something which is both inevitable (think about Steve’s frank assessment that “there are a lot of pricks in medicine”) and something which bullying targets may be able to prevent if they could only “be more likeable”, “less annoying” or “tougher”. However, it is not necessarily that medical students are lacking in resilience, particularly when it comes to traumatic patient related events, rather it is the negative impact of being bullied by senior doctors that is reported as overwhelming their personal resources (Haglund, aan het Rot, Cooper & Charney, 2009). Parallels can be drawn with the discourse around medical students and mental health. In a 2016 journal editorial, a medical doctor and educationalist, reported that despite concerns about medical student

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and trainee doctors mental health being documented over a period of 80 years, the difficulties and trepidations remain, due largely to a combination of unhelpful beliefs, values and norms which reside within medical education and medical culture (Slavin, 2016). Slavin implores for medical educationalists to recognise that medical student mental wellbeing is not simply an individual issue, rather it is a reflection of multiple environmental inadequacies (Slavin, 2016). Similarly, the researcher proposes that any future research, strategies or curriculum alterations on the issue of medical student experience and perception of bullying would benefit from the inclusion of contextual material. It is significant that one of the only identified studies that explores medical student perceptions of antecedents to ‘abuse’, also recommend that the medical curriculum should expand current programs to include topics of power, conformity, and compliance; as well as provide a safe space for students to discuss their dilemmas and methods to actively resist and enact change at an organisational level (Rees & Monrouxe, 2011). The implications stemming from the study also includes empowering medical students with knowledge on how oppression in a clinical setting may flag the presence or potential for bullying behaviours. This study cannot suggest that there is a definitive cause and effect between the presence of structural, cultural or personal oppression, and an increased risk of bullying behaviours, however it is projected that an enhanced understanding of contextual oppression may be an additional way for medical students to view the phenomenon of bullying amongst hospital-based doctors. Furthermore, students may benefit from being alerted to the concept that vulnerability to power abuse may be a result of both contextual and individual factors. Rather than perceiving and experiencing bullying behaviours solely in the realm of individual cause and effect, medical students might instead gain an increased depth and breadth of understanding on the issues, and an associated sense of empowerment in the knowledge that (unlike many of their reported perceptions), they are not exclusively responsible on an individual level for the perpetration of bullying. It might benefit medical students to recognise that if they are feeling powerless, marginalised, or exploited, and if there is a palpable sense that the dominant group is defining them, there is chance that they are at risk of exposure to bullying behaviours, to harassment, stigmatising or abrasive actions.

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Implications for further research

One of the implications for research is for further focus on exploring why, to date, medical student perception and experiences of bullying behaviours appear focused on individual aspects, rather than contextual. This study indicates benefit in further investigation of broader, multi-levelled understandings and experiences of bullying behaviours, and how an increased knowledge of structural, procedural or cultural factors may benefit medical students when dealing with abrasive or hostile physician behaviours within the hospital context. This study identified that some medical students use different definitional criteria to those used in organisational policy, regulations or legislations, which is congruent with another study on medical student understandings of abuse, flagging the potential benefit in further investigation into medical students, labelling and defining bullying behaviours amongst medical doctors. In other relatable research, sexism and sexual harassment have been documented as pervasive in medicine, which, when combined with participant insights on the influence of media, and a gap in current research exploring the issue, signifies another potential implication for further research. An expanded knowledge of how medical students and doctors perceive their own collective patterns of communication might also prove highly valuable in illuminating any role that communication behaviours, expectations and norms play in the medical student and trainee doctors experience and perceptions of bullying. Similarly to the Mendick et al. study, which explores how surgeons think they have learnt to communicate with patients (Mendick et al., 2015), further investigations may also help illuminate whether perceptions on individual or collective communications are actually consistent with or divergent from the current professionally and organisationally sanctioned modes of medical communication. Given that the vast majority of current commentary and research on the issue of bullying, harassment and other abrasive behaviours within medicine is situated from within the medical profession itself, coupled with the (documented) sluggish speed in which meaningful positive change in bullying behaviours is occurring, it seems prudent that research contributions from disciplines outside medicine may give a fresh insight or perspective to the issue.

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No known studies currently exist which investigate medical students’ perception and experiences of bullying amongst hospital-based doctors within a continuum or spectrum of their other behaviours. This gap in knowledge, coupled with the participants identifying positive behaviours amongst doctors, is an indication that further research which unpacks the full gamut of behaviours and interactions between hospital-based doctors may produce a richer contextual understanding of the setting in which bullying behaviours can occur. It may allow researchers to ascertain whether there are some circumstances within hospitals and medicine where bullying behaviours occur more often. Questions, which might be raised, includes whether there are components of medical practice that makes abrasive behaviours both foreseeable and inevitable.

Theoretical contribution

This study has introduced the possibility of viewing bullying amongst doctors through a theoretical lens of power dynamics and oppression. Moreover, the research finds that such a lens may lead to an effective and practicable way to understand, and ameliorate aspects of the issue. By specifically applying Young’s ‘Five Faces of Oppression to medical student beliefs, behaviours, and context, it becomes possible to interpret matters such as the underreporting of bullying, or the perception that targets contribute to their own victimisation, as an indicator of embedded structural oppression, and contextual systems failure, rather than flagging individual deficit.

9.5. Strengths and limitations

Strengths

This research explored a currently under-researched area, and contributes new understandings on medical student perceptions and experiences of workplace bullying amongst medical doctors. It gives a platform to medical students, their conceptualisations, insights and sometimes-painful experiences of bullying and hospital-based doctors. As the first Australian study to investigate medical student perceptions and experiences of bullying amongst hospital-based doctors, it reveals rich data on how medical students actually experience, interpret and define their observations and involvements with bullying.

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The study findings have limited, but none the less significant applicability to other allied heath disciplines that have a similar apprenticeship model within hospitals. Disciplines such as social work, , physiotherapy, and dietetics may all benefit from the studies insights and implications. There were a number of strengths in having one-on-one interviews as the data collection method. By allowing participants to share personal stories, sometimes involving elements of great personal vulnerability in a space that felt safe and respectful, the data that was collected was detailed, and nuanced in nature. The data collection method also allowed the researcher to optimise their responsiveness to the sensitive nature of the material. This study adds a different disciplinary voice to the current discourse on medical student perceptions and experiences of bullying amongst hospital-based doctors. The researcher is not a medical doctor, but rather a social worker that has both practiced and taught in the discipline of social work. As unpacked in Chapter One, it was a deliberate choice not to investigate bullying amongst social workers, but rather view the issue of bullying amongst doctors through a lens of social work experience and values. As outlined in the Australian Association of Social Workers Code of Ethics, social workers problem solve human relationships, promote social change, and champion the empowerment and liberation of individuals and collectives (AASW, 2010). Gathering the perspectives and experiences of one of the most vulnerable cohorts within the profession, the medical student, fits with a number of the social work professions commitments and aims. As a social worker, who is trained to privilege principles of social justice and human rights, and who will often work at the interface between persons and place, exploring the issue of workplace bullying through a framework of power dynamic and oppression was professionally apt. The values, professional purpose, function, culture and educational experiences of doctors may well produce a different focus to the research topic. While medical doctors themselves are driving, or generating much of the current body of knowledge on bullying within medicine, it is timely for other professions to contribute their own disciplinary wisdom and insights to the discussion.

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Limitations

As with most research there are a number of limitations identified. These are related to the nature of the research population, issues of privileging, and potential use of other data collection modes. The small participant pool is one inherent limitation to the study. Given the sensitive nature of the topic, there were some significant challenges and restrictions in recruitment, resulting in a limited number of participants. The fear shared by the participants around speaking out, and certainly reporting on, the issue of bullying behaviours in medicine, and the reluctance by others to be part of a study investigating this topic, meant that the participant pool might not have been as expansive or inclusive as anticipated. For some medical students they voiced trepidations that their Medical Faculty or the Dean of Medicine might somehow find out that they were intending to talk about abrasive, bullying behaviours in medicine. Furthermore, participants mentioned how small the medical profession is in Melbourne, and the fact that ‘everybody knows everybody’s business’, which may have further constrained the willingness for medical students to come forward and talk to their perceptions and experiences. The time poor nature of medical students, and the budget constraints of the research, also compounded the inability of researchers to expand the participant pool. It was noted that responses to online questionnaires or surveys on the subject of medical student mistreatment or abuse often yielded higher participation rates than face-to-face interviews, although it is hard to know if it was the time factor or the anonymity of the survey which impacted recruitment the most. One Canadian study that required medical students to participate in focus groups had just over a 20% uptake (Gan & Snell, 2014), whereas a recent Australian survey had a participation rate of 96.7% (Scott et al., 2015). However, while the response rate to recruitment announcements for the research was relatively low at a number of twenty three, around 70% of those students who enquired about the study went on to participate in the research, reflecting that those medical students who resolved to discuss their insights on the issue, committed to the process early on. While many of the recruited participants had completed rural placements, no participants who were enrolled in a regionally located medical school contributed to the study, possibly contracting the breadth of participant characteristic and perspective even further. Additionally, due to using university grounds for flyers, and university emails

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for recruitment notifications, the perspectives and experiences of medical students who had dropped out, or withdrawn from the medical course were not captured. The researcher was aware that the research topic and research design, including recruitment and data collection methods, would privilege those who were confident in responding to a request for a one-on-one interview on a sensitive topic, which may have been enormously confronting for other medical students. As elucidated in a paper on recruitment processes in qualitative interview studies, there is a potential risk, particularly in difficult-to-recruit studies, that during the recruitment phase, the voice of one group may begin to be represented above others (Kristensen & Ravn, 2015). As outlined in the methods section, although this research is focused on the lived experience of the participants, every effort was made to eliminate loaded or leading terms from the recruitment process. I was also reflexive that the topic might attract participants who already had a strong bias or vested interest in sharing their experiences; subsequently I suspect that the participants were actually a combination of medical students who were so amply connected to the profession of medicine through family, or friends that they felt relatively safe to share their opinions, and those medical students who were already feeling marginalised by their lived experience, and for those participants there was an element of already feeling disconnected or alienated from the profession. A consequence of this is that the opinions and insights of other medical students, who may have occupied the middle ground of experience, might not be represented. Although the research design was predominantly constructivist (interpretivist) in nature, rather than critical, there was perhaps, a missed opportunity in choosing one- one-one interviews as the data collection method, while it allowed for rich, powerful narratives to be collected, the possible limitation was that it generally disallowed a process of collective empowerment through knowledge generation and sharing (Lincoln, Lynham & Guba, 2011) amongst the medical students, which may have resulted if using a group discussion.

9.6. Conclusions

As someone who has experienced that myself, I really don’t want other people to have to go through what I went through, I think if that is to change then we really have to

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change the nature of the medical profession. I guess that’s why I wanted to participate – Matilda

As outlined in earlier chapters, the research aim was to gain an enhanced understanding of medical students’ perceptions, and experiences amongst hospital-based doctors. The research started with the suppositions that bullying amongst hospital-based doctors existed, and that medical students would be in a position to offer their insights on that occurrence. An exploration of existing literature indicated that bullying amongst doctors, in particular hospital-based physicians did occur, with high prevalence levels and a raft of negative impacts often cited. There were gaps noted in the related literature, namely a lack of focus on lived experience narratives of bullying in medicine. The gap in literature also included few explorations of contextual factors relevant to the bullying behaviours, and even fewer studies that included these elements in an Australian context. At the most elementary level it is hoped that this study adds a representation of medical student perceptions and experiences of bullying amongst hospital-based doctors. Furthermore, it is anticipated that by exploring and framing the issues developed through participant insights, with a theoretical paradigm of power dynamics and oppression, new understandings are generated. In order to adequately address the aim, the research was anchored by the three core research questions. The three research questions encompassed medical student perceptions, medical student experiences and how power and oppression dynamics might contribute to our understanding of medical student perceptions and experiences of bullying amongst hospital-doctors. In the synthesis of existing literature and participant insights, implications for medical education were formed. Most notably that any medical curriculum include a level of discussion or content around the broader context of bullying amongst hospital- based doctors, with specific focus on dynamics of power and oppression. Contribution for further research focus, included gaining a greater understanding on the phenomenon of medical student emphasis of the individual versus the contextual, as well as continuing the exploration of bullying and collective patterns of communication amongst hospital-based doctors. Further research that can unpack the impact of media influence on understandings and experience of sexism and sexual harassment for medical students was also indicated, as was the need for further studies, which explored bullying within a full continuum of doctor behaviours. That this is the first known

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research on this topic, conducted through a disciplinary lens of social work, which although a contribution in itself, it also flagged the need for other disciplines to contribute to research and illuminate the issues through their own unique disciplinary lens. In drawing any conclusion on the topic of medical students’ perceptions and experiences of bullying amongst hospital-based doctors, the complexities and tensions inherent to the subject matter must also be remembered. This research has perhaps raised as many questions as it has answered. The implications or contributions of this study are in no way intended to be used as a condemnation of those doctors who find themselves in positions of organisational or professional power. Nor are these findings an indictment of current hospitals, or of the medical education curriculum offered within Victorian universities. There are pressures, and particularities of medicine which indicate that there may be situations and context that are suited to communication or interactions that are necessarily curt or abrasive in nature, something which a study of a continuum of behaviours would possibly uncover. Given the complexities of both people and systems, it may well be an inevitability of sorts that bullying amongst hospital-based doctors may never be eradicated. Overwhelmingly though, it is the negative impact of bullying behaviours by hospital-based doctors, which was shared by participants in this study and others, that obliges the researcher to suggest the necessity for a better way forward. A future which ensures interactions between medical students, qualifying and qualified doctors alike are hallmarked less by oppressive mechanisms and instead characterised by mutual compassion, empathy, and consideration for others. In terms of increased awareness and visibility of bullying and harassing behaviours amongst doctors in Australia, the professional landscape has certainly changed since the beginning of this research. However, it is critical to keep the issue visible and firmly on the agenda, both within the medical professional itself and within the hospital systems, both public and private. Reflecting the hope and optimism that many of the medical students displayed during this investigation, this researcher is confident of a future, which, at some point, has both doctors and medical students actively working towards a medical culture typified by respectful professional relationships.

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Victorian Equal Opportunity and Human Rights Commission. (2015). Independent Review into sex discrimination and sexual harassment, including predatory behaviour in Victoria Police. Retrieved from https://www.humanrightscommission.vic.gov.au/component/k2/item/1336- independent-review-into-sex-discrimination-and-sexual-harassment-including- predatory-behaviour-in-victoria-police-phase-one-report-2015 Victorian Public Sector Commission. (2016). Data insights: Bullying in the Victorian Public Sector. Retrieved from VPSC.vic.giv.au/wp-content/uploads/2016/09/Data- Insights-3-Bullying-in-the-public-sector-FINAl-pdf Wear, D., Aultman, J.M., Varley, J.D., & Zarconi. J. (2006). Making fun of patients: medical students’ perceptions and use of derogatory and clinical humor in clinical settings, Academic Medicine, 81(5), 454-62. Weber, D. O. (2004). Poll results: Doctors’ disruptive behavior disturbs physician leaders. The Physician Executive, September-October, 6-14. Whyte, S. (2015, August 15). Sexual harassment inquiry: Senior doctors say women can also be perpetrators. The Age. Retrieved from http://www.smh.com.au/federal- politics/political-news/discrimination-inquiry-senior-doctors-say-sexual- harassment-goes-both-ways-20150812-gixbpy.html Wirtz, P. H., Elsenbruch, S., Emini, L., Rüdisüli, K., Groessbauer, S., & Ehlert, U. (2007). Perfectionism and the cortisol response to psychosocial stress in men. Psychosomatic Medicine, 69, 249-255. Workplace Research Centre. (2008). Working Conditions of doctors and nurses in NSW public hospitals survey for submission to the Garling Inquiry. Sydney: The University of Sydney. WorkSafe Victoria. (2005). Workplace violence and bullying Retrieved from http://www.vfbv.com.au/region/13/documents/vwa_violence_bull.pdf WorkSafe Victoria. (2012). Your Guide to workplace bullying – prevention and response. Retrieved from, https://www.worksafe.vic.gov.au/__data/assets/pdf_file/0010/211006/ISBN- Workplace-bullying-prevention-response-2012-10.pdf Wyber, R., Khashram, M., Donnell, A., & Myer-Rochow, G. Y. (2013). The Gr8est Good: Use of text messages between doctors in a tertiary hospital. Journal of Communication in Healthcare, 6(1), 29 - 34. Yildirim, D., Yildirim, A., & Timucin, A. (2007) Nursing Ethics, 14(4), 447–463.

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Appendices

Appendix 1. Research journal

Sample #1

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Sample #2

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Appendix 2. Field notes sample

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Appendix 3. Correspondence on ethics committee approval

Dear A/Prof Harms

I am pleased to advise that the Behavioural and Social Sciences Human Ethics Sub-Committee has approved the following Project:

Project Title: Exploring medical students' perceptions of hostile intra- professional workplace interactions among hospital-based doctors. Researchers: A/Prof L K Harms, Ms C Lambert, Dr D J Rose Ethics ID: 1341085

The Project has been approved for the period: 17-Feb-2014 to 31-Dec-2014 A signed letter confirming this approval will be forwarded to you shortly.

It is your responsibility to ensure that all people associated with the Project are made aware of what has actually been approved.

Research projects are normally approved to 31 December of the year of approval. Projects may be renewed yearly for up to a total of five years upon receipt of a satisfactory annual report. If a project is to continue beyond five years a new application will normally need to be submitted.

Please note that the following conditions apply to your approval. Failure to abide by these conditions may result in or discontinuation of approval and/or disciplinary action.

(a) Limit of Approval: Approval is limited strictly to the research as submitted in your Project application.

(b) Variation to Project: Any subsequent variations or modifications you might wish to make to the Project must be notified formally to the Human Ethics Sub- Committee for further consideration and approval. If the Sub-Committee

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considers that the proposed changes are significant, you may be required to submit a new application for approval of the revised Project.

(c) Incidents or adverse effects: Researchers must report immediately to the Sub-Committee anything which might affect the ethical acceptance of the protocol including adverse effects on participants or unforeseen events that might affect continued ethical acceptability of the Project. Failure to do so may result in suspension or cancellation of approval.

(d) Monitoring: All projects are subject to monitoring at any time by the Human Research Ethics Committee.

(e) Annual Report: Please be aware that the Human Research Ethics Committee requires that researchers submit an annual report on each of their projects at the end of the year, or at the conclusion of a project if it continues for less than this time. Failure to submit an annual report will mean that ethics approval will lapse.

(f) Auditing: All projects may be subject to audit by members of the Sub- Committee. If you have any queries on these matters, or require additional information, please contact me using the details below.

Please quote the ethics ID number and the title of the Project in any future correspondence.

On behalf of the Sub-Committee I wish you well in your research.

Mr Tony Callahan Secretary, Behavioural and Social Sciences HESC Phone: 8344 2067, Email: [email protected]

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Appendix 4. Consent document for participant interviews

Consent Form

Exploring medical students’ perceptions of hostile intra-professional workplace interactions amongst hospital-based doctors

Participant:______

Investigator:______

1. I consent to participate in this project, the details of which have been explained to me, and I have been provided with a written plain language statement to keep. 2. I understand that after I sign and return this consent form, the researcher will retain it. 3. I understand that my participation will involve an interview and I agree that the researcher may use the results as described in the plain language statement. 4. I acknowledge that: (a) the possible effects of participating in the interview have been explained to my satisfaction; (b) I have been informed that participation is completely voluntary and that I am free to withdraw any unprocessed data that I have provided; (c) The project is for the purpose of research; (d) I have been informed that the confidentiality of the information I provide will be safeguarded subject to any legal requirements; (e) I have been informed that with my consent the interview will be audiotaped and I understand that the audiotapes will be stored at the University of Melbourne and will be destroyed after five years; (f) My name will be referred to by a pseudonym in any publications or presentations that arise from the research; (g) I have been informed that a copy of the research findings will be forwarded to me, should I agree to this.

I consent to this interview being audiotaped ☐ Yes ☐ No (please tick) I wish to receive a copy of the summary project report on research findings ☐ Yes ☐ No (please tick) Your email address: ______Participant signature______Date:______

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Appendix 5. Plain language statement

Page 1 of 2.

Plain Language Statement

Exploring medical students’ perceptions of hostile intra- professional workplace interactions among hospital-based doctors.

Introduction

As a medical student who has experience working in an acute hospital setting we would like to invite you to be part of this study. The aim of the project is to better understand the experience of interpersonal workplace hostility amongst doctors. This project has been approved by The University of Melbourne Human Research Ethics Committee, and is considered a standard risk study (Ethics ID number: 1341085). It is being completed as part of a PhD under the supervision of Associate Professor Louise Harms and Dr David Rose.

What will I be asked to do?

You will have been emailed a copy of the consent form to read, at the same time that you received this statement. Should you agree to be involved, you would be asked to participate in one in-depth, one-on-one interview at a time convenient to you. You will then be asked at the interview to sign the consent form before the commencement of the interview. The questions asked will include questions around organisational and professional context, intra-professional workplace interactions, and your understanding negative intra-professional workplace interactions. With your permission, the interview will be audio-recorded so that I can ensure we have an accurate record of what you say. You can request a transcript of your recording if you wish to verify the information is correct and/or request deletions. It is anticipated that the total time commitment will be around 20 - 30 minutes.

How will my confidentiality be protected?

We intend to protect the confidentiality of your interview responses to the fullest possible extent, obviously within the limits of the law. The identity of hospitals, specialities, units or geographical locations where you have had experience will be anonymised. Your name and contact details will be kept in a separate, password protected computer file from any data you supply. All data gathered will be de- identified. Study participants can be confident that any identifying markers will be removed from the transcripts. Names will not be written on the tape or in filing, and you will be assigned a pseudonym. Descriptions of stories, examples or cases or events will be anonymised in any material published. The data will be securely stored at The University of Melbourne and will be destroyed 5 years after the date of publication.

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Page 2 of 2.

Possible effects of participation

Discussing hostile or negative intra-profession workplace interactions may trigger emotions or thoughts that you may find distressing. A list of psychological supports and services will be made available at the end of the interview.

How will I receive feedback?

Should you wish to receive feedback about the project upon thesis completion, a brief summary of the finding will be available on request. It is anticipated that from data collected, articles will be published, reports written, and presentations will be made at conferences. The thesis will be available for you to access at the University of Melbourne’s library.

Will participation me in any way?

Your participation in this study is completely voluntary. Should you wish to withdraw the unprocessed data you have supplied, you are free to do so without prejudice. Unprocessed data includes data that has not been transcribed, coded, compared or analysed in any form by the project’s researchers.

If you have any concerns about the conduct of this research please contact the Executive Officer The University of Melbourne Human Research Ethics T: 83442073 F: 93476739

How do I agree to participate?

If you would like to participate in the study, or have further questions please contact: Ms Caroline Lambert T: 0448814434 E: [email protected]

A mutually convenient time and place for you to participate in the interview will be arranged. Interviews can either be conducted on University of Melbourne grounds, or at an alternative convenient location.

Ms Caroline Lambert (PhD Student) Associate Professor Louise Harms Dr David Rose [email protected]

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Appendix 6. Recruitment flyers

UoM Learning Management System email

Dear medical student

You are invited to share your views on workplace interactions between doctors.

This PhD research, aims to explore your perceptions on hostile or abrasive interactions, which may occur amongst doctors working or studying in hospitals.

Exploring medical students’ perceptions of hostile intra-professional workplace interactions among hospital-based doctors.

If you have questions or are interested in participating in this research, and wish to privately discuss your views on this subject, please contact:

Caroline: T: 0448 814 434

[email protected]

It is anticipated that interviews will last between 20 – 30 minutes. They can be conducted at the Parkville university campus, or in another more convenient location. Measures are in place to safeguard participant anonymity and confidentially.

Plain language statement PLS

Ethics ID: 1341085

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Recruitment flyer sample #2

The University Of Melbourne Faculty of Medicine, Dentistry and Health Sciences School of Health Sciences

Exploring medical students’ perceptions of hostile workplace interactions among hospital-based doctors.

Medical students: You are invited to share your views on workplace interactions between doctors.

This PhD research aims to explore your perceptions of hostile or abrasive interactions, which may occur amongst hospital-based doctors.

If you are a medical student, and have some hospital placement experience, you are eligible to participate. If you have questions or are interested in participating in this research, and wish to privately discuss your views on this subject, please contact:

Caroline: T: 04488 1434 [email protected]

It is anticipated that interviews will last between 20 – 30 minutes. They can be conducted at the Parkville university campus, or in another more convenient location. Measures are in place to safeguard participant confidentially.

Ethics ID: 1341085

[email protected] Caroline: 0448814434 Exploring medical student perceptions [email protected] Caroline: 0448814434 Exploring medical student perceptions [email protected] Caroline: 0448814434 Exploring medical student perceptions [email protected] Caroline: 0448814434 Exploring medical student perceptions [email protected] Caroline: 0448814434 Exploring medical student perceptions [email protected] Caroline: 0448814434 Exploring medical student perceptions [email protected] Caroline: 0448814424 Exploring medical

student perceptions

nimelb.edu.au

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Appendix 7. Letter to a recruitment gatekeeper

22-12-2013

Dear Mr Callahan

Re: Ethics application – ‘Exploring medical student’s perceptions of hostile intra- professional workplace interactions amongst hospital-based doctors’ (ID 1341085)

I am writing in support of this project, to be undertaken by Ms Caroline Lambert for her doctoral studies. I am the Chair of Ms Lambert’s Doctoral Committee, and therefore have been contributing to discussions regarding the design of this study. In my capacity as Director of The University of Melbourne’s Medical Education Unit, I am willing to facilitate recruitment for this worthwhile and timely project.

The Medical Education Unit will support recruitment of participants into the project by providing project information to all MD students via the Learning Management System, consistent with the process outlined in Ms Lambert’s ethics application.

Bullying amongst doctors is still a relatively new area of research, but primary studies indicate that these hostile interactions are widespread, and often have negative outcomes for all those involved. There appears to be a genuine need for a study that not only examines negative workplace interactions amongst physicians, but one that actively explores what and how, early career doctors initially form their perceptions of the behaviour. This project aims to address the current deficit in both research and literature in the area.

The focus on medical students, and how they subjectively perceive hostile interactions amongst doctors, is of pivotal importance to the research. It allows us an insight into how students understand and define abrasive intra-professional behaviours amongst physicians, behaviours that the students may not have previously encountered, either within their chosen profession, or within the hospital context. It is the exploration of how the enculturation process might influence medical students’ perceptions, which makes this research particularly valuable. This study has the potential to positively influence and inform workplace and professional body bullying policy, as well as aspects of a medical students’ university based learning.

Please do not hesitate to contact me if you would like to discuss the project further.

Yours sincerely,

Professor Geoff McColl Deputy Dean, Faculty of Medicine, Dentistry and Health Sciences Director, Medical Education Unit

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Appendix 8. Interview guides

Sample #1

Page 1 of 4.

Interview Guide (Unamended version – ethics approved)

Introduction

Thank you for being willing to take part in this interview.

The interview is part of the data collection process for my PhD project. The purpose of the research is to increase our insight into how medical students understand certain interactions amongst their colleagues. This study explores medical students’ perceptions of intra-professional workplace interactions. As a medical student with clinical placement experience in an acute hospital you are ideally placed to be able to answer some of the research questions.

We intend to protect your the confidentiality of your interview responses to the fullest possible extent, obviously within the limits of the law. It is anticipated that from that data, articles may be published, reports or feedback may be given to appropriate and interested parties (i.e. AMA) and presentations may be made. It is expected that information gathered, and analysed may also be used to inform strategy or intervention aimed at combating any areas identified by participants for improvement.

There is a link to the plain language statement (PLS) on the LMS research advert, and a copy of the PLS, and consent form was emailed through to you earlier. If you have any further questions around either document feel free to ask me questions.

(Check if participant has signed consent. If not, request participant to sign)

There may be some questions in this interview that you find difficult to answer. There are no right or wrong answers; we are interested in your opinions and personal experiences.

Feel free to interrupt, or ask for clarification of the interviewer.

I would like to audio-record this interview so that I can ensure we have an accurate record of what you say. You can request a transcript of your recording if you wish to verify the information is correct/ and/ or request deletions.

It is anticipated that the interview will take around 30 minutes.

Should you feel distressed at any time during the interview process, please let me know, and we can take a break. You are of course free to withdraw from the interview or the project at any time, and to withdraw any unprocessed data gathered here today.

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Page 2 of 4.

If you find the content or process of this interview upsetting there are a number of resources and supports available to you through either your workplace or the wider community. I have a list of these resources here for you if required.

Key concepts

Organisational and professional context

1. Do you think of yourself as a trainee doctor, doctor or medical student?

2. Does this differ to how others might perceive you, personally and professionally? How so?

Prompt: inclusive of other professions etc..

3. What criteria do you use to figure this rank out?

4. Where would you rank yourself within your professional hierarchy? Prompt: Amongst doctors only. Chain of command

5. Do you feel you have an ability to influence others? How?

6. Do you think that your workplace or profession has a particular culture relating to workplace intra-colleague interactions? Tell me a bit more about that culture. How would you describe it?

7. Are you aware of any hospital policy or regulations around employee interactions? What behaviour do you think it specifically relates to?

Your experiences of intra-professional workplace interactions

These questions will ask you about your own experiences or observations of hospital-based intra-professional interactions

8. How would you characterise most of your daily interactions with your medical colleagues?

9. Have you ever been involved, or witnessed a hostile or abrasive interaction with another doctor?

Prompt: action, behaviour or words.

10. What did the behaviours or actions look like?

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Page 2 of 4.

11. How did this incident make you feel at the time?

Prompt: emotion, reaction, i.e. not bothered, distressed, confused

12. Has that feeling changed? If so how?

13. What label (if any) would you use to describe the incident? Why?

Understanding negative intra-professional workplace interactions

14. I am going to ask you to read a hypothetical workplace interaction between two doctors.

Give them the scenario (on separate page) and once they have finished reading the scenario, I will read the 4 questions related to the hypothetical out to the participant.

15. Can you think of a time in your professional life, where you chose not to report a hostile or abusive interaction with a colleague?

What happened?

16. Can you think of any reasons that the target of a hostile interaction between doctors might tolerate the behaviour, or not report the incident?

17. Why do you think that bullying might occur between doctors?

18. Do you feel that your perception of behaviour by other doctors is acceptable or unacceptable has altered over time? How?

To finish

Is there anything else you’d like to discuss in relation to this topic?

Thank you for your time today. If you have any questions regarding the study, please don’t hesitate to contact me. My contact details can be found on the plain language statement I gave you at the beginning of the interview.

If you have found the topic of this interview distressing, please take a copy of the available resources and supports.

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Page 4 of 4.

Case Scenario

A senior doctor shouts at a junior doctor for not answering their questions quickly enough. They do it in front of other staff and patients. This happens on a fairly regular basis, and the junior doctor is starting to question their own capacity to one day be a competent doctor. At times the junior doctor feels humiliated, and where possible, they have started avoiding interactions with the senior doctor.

1. What thoughts or emotions do you have on the behaviour of the senior doctor?

2. Would you describe the senior doctor’s behaviour as acceptable, or justifiable?

3. If you felt the senior doctor’s behaviour was not acceptable in this scenario, are there any circumstances in your workplace where you’d consider that this behaviour might be justifiable? Try and describe that scenario for me.

4. Some might consider the behaviour of the senior doctor to be workplace bullying, what do you consider the behaviour of the senior doctor to be? What words or labels would you use to describe the senior doctor’s behaviour?

5. Is there any other information about this scenario that you would want to know before you would label it as bullying? What is it?

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Sample #2

Page 1 of 4.

Interview Guide

Introduction

Thank you for being willing to take part in this interview.

The interview is part of the data collection process for my PhD project. The purpose of the research is to increase our insight into how medical students understand certain interactions amongst their colleagues. This study explores medical students’ perceptions of intra-professional workplace interactions. As a medical student with clinical placement experience in an acute hospital you are ideally placed to be able to answer some of the research questions.

We intend to protect your the confidentiality of your interview responses to the fullest possible extent, obviously within the limits of the law. It is anticipated that from that data, articles may be published, reports or feedback may be given to appropriate and interested parties (i.e. AMA) and presentations may be made. It is expected that information gathered, and analysed may also be used to inform strategy or intervention aimed at combating any areas identified by participants for improvement.

There is a link to the plain language statement (PLS) on the LMS research advert, and a copy of the PLS, and consent form was emailed through to you earlier. If you have any further questions around either document feel free to ask me questions.

(Check if participant has signed consent. If not, request participant to sign)

There may be some questions in this interview that you find difficult to answer. There are no right or wrong answers; we are interested in your opinions and personal experiences.

Feel free to interrupt, or ask for clarification of the interviewer.

I would like to audio-record this interview so that I can ensure we have an accurate record of what you say. You can request a transcript of your recording if you wish to verify the information is correct/ and/ or request deletions.

It is anticipated that the interview will take around 30 minutes.

Should you feel distressed at any time during the interview process, please let me know, and we can take a break. You are of course free to withdraw from the interview or the project at any time, and to withdraw any unprocessed data gathered here today.

255

Page 2 of 4.

If you find the content or process of this interview upsetting there are a number of resources and supports available to you through either your workplace or the wider community. I have a list of these resources here for you if required.

Key concepts

Organisational and professional context

1. Do you think of yourself as a trainee doctor, doctor or medical student?

2. Does this differ to how others might perceive you, personally and professionally? How so?

Prompt: inclusive of other professions etc..

3. Do you feel you have an ability to influence others? Who and How?

4. Do you think that hospitals have a particular culture relating to work based exchanges/communications between doctors? Tell me a bit more about that culture. How would you describe it?

5. Do you think that your profession (medicine) has a particular culture relating to interactions or exchanges between doctors.

6. Are you aware of any hospital policy or regulations around employee interactions? What behaviour do you think it specifically relates to?

Your experiences of hospital-based interaction or exchanges between doctors

These questions will ask you about your own experiences or observations of interactions between doctors.

7. How would you characterise most of your daily interactions with your medical colleagues?

8. Have you ever been involved, or witnessed a hostile or abrasive interaction with another doctor?

Prompt: action, behaviour or words.

9. What did the behaviours or actions look like?

10. How did this incident make you feel at the time?

Prompt: emotion, reaction, i.e. not bothered, distressed, confused

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Page 3 of 4.

11. Has that feeling changed? If so how?

12. What label (if any) would you use to describe the incident? Why?

Understanding negative intra-professional workplace interactions

13. I am going to ask you to read a hypothetical workplace interaction between two doctors.

Give them the scenario (on separate page) and once they have finished reading the scenario, I will read the 4 questions related to the hypothetical out to the participant.

14. Can you think of a time in your professional life, where you chose not to report a hostile or abusive interaction with a colleague?

What happened?

15. Can you think of any reasons that the target of a hostile interaction between doctors might tolerate the behaviour, or not report the incident?

16. Why do you think that bullying might occur between doctors?

17. Do you feel that your perception of behaviour by other doctors is acceptable or unacceptable has altered over time? How?

To finish

Is there anything else you’d like to discuss in relation to this topic?

Thank you for your time today. If you have any questions regarding the study, please don’t hesitate to contact me. My contact details can be found on the plain language statement I gave you at the beginning of the interview.

If you have found the topic of this interview distressing, please take a copy of the available resources and supports.

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Page 4 of 4.

Hypothetical case scenario

A senior doctor shouts at a junior doctor for not answering their questions quickly enough. They do it in front of other staff and patients. This happens on a fairly regular basis, and the junior doctor is starting to question their own capacity to one day be a competent doctor. At times the junior doctor feels humiliated, and where possible, they have started avoiding interactions with the senior doctor.

6. What thoughts or emotions do you have on the behaviour of the senior doctor?

7. Would you describe the senior doctor’s behaviour as acceptable, or justifiable?

8. If you felt the senior doctor’s behaviour was not acceptable in this scenario, are there any circumstances in your workplace where you’d consider that this behaviour might be justifiable? Try and describe that scenario for me.

9. Some might consider the behaviour of the senior doctor to be workplace bullying, what do you consider the behaviour of the senior doctor to be? What words or labels would you use to describe the senior doctor’s behaviour?

10. Is there any other information about this scenario that you would want to know before you would label it as bullying? What is it?

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Appendix 9. Demographic Questions List

Demographic data sheet

1. Age group (i.e. 20 -29, 30-39, 40 -49)

2. Gender (F, M)

3. Country of birth

4. Race/ethnicity you would identify with

5. Family members or close friends who are physicians, yes or no

6. Formal occupational title within last hospital placement

7. Where would you rank yourself within your organisational hierarchy?

8. Where would you rank yourself within your organisational hierarchy?

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Minerva Access is the Institutional Repository of The University of Melbourne

Author/s: Lambert, Caroline

Title: Exploring medical students' perceptions and experiences of bullying amongst hospital-based doctors

Date: 2017

Persistent Link: http://hdl.handle.net/11343/198147

File Description: Exploring Medical Students' Perceptions and Experiences of Bullying Amongst Hospital- Based Doctors

Terms and Conditions: Terms and Conditions: Copyright in works deposited in Minerva Access is retained by the copyright owner. The work may not be altered without permission from the copyright owner. Readers may only download, print and save electronic copies of whole works for their own personal non-commercial use. Any use that exceeds these limits requires permission from the copyright owner. Attribution is essential when quoting or paraphrasing from these works.