Recent hospital training inspection reports have made for stark reading with regard to bullying and undermining of NCHDs.
The reports of inspections at the Saolta University Health Care Group and South/South West Hospital Group were published by the Medical Council on 15 August, the first occasion it had actively released this type of report into the public domain.
Prior to this, on 2 July, the Medical Independent (MI) submitted requests to the two Hospital Groups seeking the reports under Freedom of Information (FoI) legislation, and these requests were pending upon their public release.
The documents reveal an array of good and bad practice across the Groups in relation to compliance with the Council’s standards for intern and specialist training.
But undermining and bullying are recurrent issues, with some troubling insights revealed in the reports.
Junior doctors at Letterkenny University Hospital, for example, told of how there were signs on the door of the radiology department that stated ‘No NCHDs’.
At South Tipperary General Hospital, trainees “did not feel protected against bullying” and gave examples of “interdisciplinary bullying they had either experienced or witnessed”.
A breakdown of relations in some wards at Portiuncula University Hospital was highlighted by the case of an intern “being telephoned by a nurse who did not identify themselves, did not address the doctor by name and simply stated ‘ECG needs to be done now’.”
Interns at Mercy University Hospital in Cork reported incidents where some members of the radiology department “had treated them very unprofessionally when attempting to order scans”. They also gave examples of “disrespectful treatment by nursing staff”.
Male interns at the Mercy reported they received “preferential treatment to that of their female colleagues from nursing staff while on-call”. Interns believed reporting such incidents “could have an adverse effect on them”.
The inspection team noted a lack of awareness about how to raise a concern around policies such as the Dignity at Work Policy (the HSE’s anti-bullying, harassment and sexual harassment policy and procedure).
At Cork University Hospital (CUH), a major teaching hospital, trainees were unaware of the protected disclosure policy. Some trainees were also unaware of the Dignity at Work Policy, despite it being included in the induction programme and the Charter of Rights for Doctors in Specialist Training.
CUH trainees stated they “would be unsure what to do in the event of witnessing or experiencing inter-disciplinary bullying… There was no sense that reported incidents had been acted upon, as there was an absence of any feedback”.
Dr John Duddy, neurosurgery SpR
HSE staff survey
The HSE’s staff survey in 2016 identified bullying and harassment as prevalent in the Irish health service. Some 31 per cent of respondents reported experiencing bullying and/or harassment in their organisation in the previous two years.
Almost half (46 per cent) reported witnessing bullying and/or harassment in the previous two years in their organisation, while 28 per cent said they had been subject to assault — verbal or physical — in their organisation in the previous two years.
One-in-five said they had experienced discrimination from a manager/team leader or other colleagues in the previous 12 months.
As reported in MI in August, the HSE paid just over €28,000 in compensation as a result of bullying and harassment complaints between 2014 and 2017.
Over the four-year period, there were 154 cases of alleged bullying/harassment that resulted in a formal investigation, revealed figures released under FoI legislation.
Most of the cases (74) were in 2015. In 2014, there were 30 cases; 16 in 2016; and 34 in 2017.
Regarding the 30 cases reported in 2014, 11 investigations were in progress and nine were awaiting report. There had been four “disciplinary actions”. Only one complaint had been upheld, one had been partly upheld, three had not been upheld, while one staff member had resigned.
In relation to 74 cases in 2015, there had been one dismissal; three cases where a final written warning was issued; and two cases where the disciplinary procedure was still in process. One case was referred to the Director General, another case was resolved through mediation, and one case was still under discussion.
For 2016, in respect of 16 cases, one had resulted in sanction. In another, it was decided there was “no case to answer”. There were 14 investigations in progress, “some due to [a] parallel process”.
In 2017, of the 34 reported cases, 29 investigations were still in progress.
In one case there was no formal conclusion, while four disciplinary sanctions had been imposed.
The Medical Council’s Your Training Counts series has also highlighted that bullying, undermining and harassment of doctors in training are major issues. The Council has said it appears bullying is “endemic” in the system.
According to Your Training Counts: Trainee Experiences of Clinical Learning Environments in Ireland 2014-2016, one-third of trainees reported being bullied or undermined in-post. Over half had witnessed someone else being bullied or undermined and harassed in-post.
“Undermining behaviour towards trainees is reportedly more prevalent in doctors, mainly consultants and GPs; or nurses/midwives — although in the latter cases, this was more prevalent among interns,” according to the report.
“Trends show that interns in general are more likely to be bullied, undermined or harassed in-post, particularly in surgical or medical training posts; and/or trainees in smaller and larger hospitals (as opposed to GP practices or mental health services). With trends indicating that trainees are most likely to be bullied by a trainee at the next level/grade up from their own, this indicates that bullying is endemic throughout the system.”
Dr John Duddy, Specialist Registrar in Neurosurgery, was particularly vocal about the issue of bullying during his tenure as IMO President in 2016/17.
There is no discernible sense that this matter has improved, according to Dr Duddy. However, anecdotally, he has found that “NCHDs are less tolerant of being treated unfairly” and appear to be more likely to raise such issues.
Training bodies have “stepped up” but the approach of hospitals to the problem requires major improvements, he added.
The former IMO President also believes a “culture change” is needed in how healthcare professionals speak to each other. Dr Duddy was unsure if the HSE’s Values in Action initiative provides the answer in this regard, as it may be seen as just another ‘management policy’.
Dr Duddy added that interns were the “primary victims of bullying and undermining in hospitals” and were often viewed as “bottom of the food chain”.
At the IMO’s 2016 AGM, Dr Duddy spoke out about his personal experience of having been bullied in the workplace.
“I know what it’s like to have my performance in the operating theatre consistently undermined every day,” he told delegates.
Reflecting on the situation, Dr Duddy emphasised the important role and influence of people who witness bullying and undermining behaviours. “There were lots of people who could have stepped in and said, ‘that’s not an acceptable way to treat someone in the workplace’”, he told MI.
He said the Medical Council should have a much more active role in addressing such behaviours, as they constitute unprofessionalism. He said information-gathering alone cannot suffice.
A doctor who anonymously comments on health service issues via the Twitter account FacelessJuniorDoctor told MI “bullying is actually part of the culture in Irish hospitals”.
This doctor continued: “It mostly goes on when a junior has to call an on-call senior and ask for help/specialised opinion. Speaking to that junior in an outright rude, aggressive and belittling manner is entirely the norm. It’s bizarre. I’ve never heard the like of it in other organisations.
“Maybe it has something to do with on-call staff being completely overrun now, because our doctor-to-patient ratio is low and getting lower, but there is a level of acceptance of this kind of behaviour and it’s shocking.”
Memo to staff
On 17 August last, Ms Rosarii Mannion, HSE National Director of Human Resources, issued a memo to all staff in the health service on preventative measures in relation to bullying and harassment in the workplace.
This memo stated it was recognised that “environmental factors and resource shortages may place pressures on different parts of the system, nonetheless, this does not alter the requirement for all staff to be treated with dignity and respect”.
It underlined that all supervisors and managers had a specific responsibility to promote the Dignity at Work Policy in the workplace, foster positive behaviours and address conflict locally.
“In this regard, all managers and supervisors are required to revisit the Dignity at Work Policy in the setting of a team meeting in order to re-state rights and responsibilities of employees under the policy. The team discussion should offer an opportunity to provide clarity on both the role of the manager and the role of the employee.”
The HSE “has committed to in-depth training interventions across the organisation, whilst a 24-hour helpline Staffcare is available on 1800 409 388”, it added.
Speaking to MI, Ms Mannion said this issue has been a particular focus for HSE HR since the 2016 staff survey results. “We are redoubling our efforts now, in terms of the supports that are there. We are improving, it is absolutely improving, but we have a lot more to do and it will definitely be a very key area of focus in terms of the deployment of the central resource in 2019.”
Currently, the Executive is running multidisciplinary training workshops and has developed and launched an online training programme around Dignity at Work.
Ms Mannion explained a taskforce has also been established looking specifically at issues of bullying and harassment across the organisation. She has appointed two people to act as points of contact, should staff not wish to raise an issue in their immediate workplace.
“We also have the Respect Charter with the IMO and we are working on implementing that.”
It has been suggested that healthcare unions may stymie the disciplinary process, which could impact on the sanctioning of those found to have bullied or harassed a colleague.
Ms Mannion said there was “no barrier” in that respect. “We use our policies as they are, to make sure we are addressing issues. Ideally, you would want to be in the preventative space, looking at early warning systems and data, and trying to ensure the environment is right, that you don’t have many cases coming through to disciplinary stage.
“What we are finding is there is an awareness — there is absolutely an awareness of the policy,” Ms Mannion said. “People know about it, they understand it.” However, she conceded “there are gaps in implementation”.
“The organisation is taking this issue extremely seriously. We really want a culture where staff are respected and valued, and from a HR point of view, we will be doing everything to ensure that that materialises.”
The HSE has also been working with Dublin City University’s (DCU) Anti-Bullying Centre on the issue.
In 2017, the Centre entered into a research agreement with the HSE, which includes a study related to tackling workplace bullying in healthcare professions and services.
The Executive has funded a postdoctoral researcher in bullying to lead this work. “The position will build on existing international research on workplace bullying and will focus on developing solutions to tackle bullying in healthcare professions and services in Ireland,” according to the job spec.
“The position is funded by the HSE and the person appointed will be the main point of contact for the programme of research with the HSE. The selected candidate will work under the leadership of the Centre’s Director (Principal Investigator) and contribute to the development of the Anti-Bullying Research Centre.”
Ms Rosarii Mannion, HSE National Director of HR
Dr Angela Mazzone, Researcher at DCU’s Anti-Bullying Centre, told MI it is known from literature that healthcare workers are more exposed to workplace bullying than those who work in other sectors.
“We know that workplace bullying negatively affects productivity and so it affects performance at work and also the psychological health of the workers — it is related to somatic symptoms, depression, burnout, and it even affects the meaning of work and the motivation of employees.”
An important point to note is that bullying is not always perpetrated by a manager against a subordinate. It can take various forms, including between people who are “on the same level”.
Bullying within the nursing profession has been particularly well-researched internationally and some interesting theories have emerged on this topic.
“If we look at the healthcare context, bullying among nurses has been widely described in the literature [internationally],” Dr Mazzone noted. “There is a sociological theory which is very interesting. It seems that the kind of bullying that happens between nurses is an example of ‘horizontal violence’, which is violence among social equals. And they are supposed to be, according to this theory, members of an oppressed group — so they are oppressed because they are rendered powerless by the medical establishment.
“Those who formulated this theory believe that some organisational factors, not just suppression, lead to bullying among nurses.”
On best practice to address bullying in healthcare, Dr Mazzone said: “We know from scientific studies that the most effective intervention programmes are those programmes which include different components — we call them ‘multi-component programmes’ and they have a whole-organisation approach, which means they address both the individual and the organisation, because workplace bullying is not just about the perpetrator and the victim, but it is [about what is] needed to address the culture of the organisation.”
Meanwhile, Ms Jantze Cotter, the Medical Council’s Director of Professional Development and Research, told MI the publication of inspection reports is the beginning of an ongoing process.
“The team that does the site inspection goes back to that site and gives them the report, and puts in place mechanisms, timeframes, around what they need to do,” she commented.
Ms Jantze Cotter, Medical Council
According to Ms Cotter, these inspection reports and data from the Your Training Counts series have helped move anecdotal accounts of bullying and undermining in the health system into the realm of “concrete evidence”.
“And we all need to work together to address that,” Ms Cotter said, referencing the training bodies, employers and the Council. “We are looking at doing a number of forums and roadshows next year that deal with the issues that come out of bullying — burnout, low sense of wellbeing — and you would have seen the information and message that our new President [Dr Rita Doyle] has been articulating around — that these are going to be a high priority for us going forward.”
However, if a site had a persistent issue with bullying and non-compliance with national policy, could accreditation be at risk?
If the Council had “major concerns” about a training site, it could advise the Minister for Health.
“If matters were so significant around training of doctors… [the Council] can make recommendations to the Minister… That is the process if that was to happen,” said Ms Cotter, who was not aware of any such recommendation over recent years.
There are also instances where complaints about unprofessional behaviour and bullying are submitted to the Council, including by other doctors and healthcare professionals. In some cases, these complaints trigger a performance assessment of a doctor.
“We have a performance assessment team, which is in my remit, and we send the doctors off to courses or we ask them to do some reflective practice or we ask them to get a mentor and address those issues — and they are monitored and we sign them off when we feel this has been satisfactorily addressed.”
Your Training Counts data from 2018 shows “an increase in reporting of bullying”, which echoes Dr Duddy’s observation that trainees are somewhat more comfortable in raising the matter than in the past.
“The trend over time has shown a gradual increase in the incidence of reporting,” Ms Cotter said.
Nevertheless, under-reporting remains an issue of concern. “Anecdotally, we suspect that instances of alleged bullying may be under-reported,” stated Mr Anthony Owens, IMO Director of Industrial Relations (Consultants and NCHDs).