The silent epidemic
Morbidity patterns from general practice worldwide highlight the high prevalence of mental health problems, the commonest being depression, anxiety, and sleep disturbance. Many of the sufferers admit to stress at work, and some of them are casualties of workplace bullying, defined as persistent, offensive, abusive, intimidating, malicious, or insulting behaviour; abuse of power; or unfair penal sanctions. These make the recipient feel upset, threatened, humiliated, or vulnerable, undermine their self confidence and may cause them to suffer stress.1 Rayner and Hoelt describe five categories of bullying behaviourthreats to professional status, threats to personal standing, isolation, overwork, and destabilisation.2
A deadly combination of economic rationalism, increasing competition, "downsizing," and the current fashion for tough, dynamic, "macho" management styles have created a culture in which bullying can thrive, producing "toxic" workplaces.3 Such workplaces perpetuate dysfunction, fear, shame, and embarrassment, intimidating those who dare to speak out and nurturing a silent epidemic. Various studies point to an emerging global phenomenon with a growing evidence base particularly from Scandinavia,4 where Sweden and Norway are the only European countries with legislation specific to bullying.
Workplace bullying has been estimated to affect up to 50% of the United Kingdom's workforce at some time in their working lives,5 with annual prevalences of up to 38%, and is becoming increasingly identified as a major occupational stressor.6 In the United Kingdom costs have been estimated at £2-30bn ($3-48bn; 3-44bn) per annum,6 although research indicates figures closer to the lower end of the range.
Of particular concern is the growing evidence of bullying among healthcare workers. A 1996 questionnaire survey of 1100 employees of an NHS community trust found 38% reported being subjected to bullying in the workplace in the previous year, and 42% had witnessed the bullying of others.7 Staff who had been bullied had lower levels of job satisfaction and higher levels of job induced stress, depression, anxiety, and intention to leave. Similar rates were found in a recent survey of 1000 junior hospital doctors in the UK.8
The obvious question remains, "What can be done?" As practitioners we should be more aware of the possibility that workplace bullying may be contributing to the stress with which many of our patients present. Questions like "How are things at work?" should also become part of routine inquiry in patients presenting with anxiety, depression, or sleep disturbanceproviding an opportunity to raise bullying. Bullying can also manifest itself in cognitive effects such as concentration problems, insecurity, and lack of initiative.9
When identified, we should be supporting and encouraging our patients in combating bullying. As general practitioners we should adopt an advocacy role for our patients and offer appropriate intervention after obtaining explicit informed consent. To be most effective in this role we need to be familiar with the issues and to know where to seek appropriate advice and helpmuch practical information and advice on identifying, preventing, and combating bullying is available on the internet and in books, 3 6 and can be adapted for handouts for patients' education. In addition, occupational health doctors and nurses can be helpful sources of advice and support, but effective communication between general practitioners and occupational doctors is unfortunately uncommon.10 A number of interventions to change workplace factors that have been shown to reduce psychological ill health include counselling, training to manage stress, cognitive behavioural therapy, and workplace support programmes.
The medical profession is under ever increasing public scrutiny, and levels of accountability continue to rise. However, statistics from the UK national workplace bullying advice line show that 20% of cases are from the education sector, 12% from health care, 10% from social services, and 6-8% from the voluntary sector.6 We need to set our own house in order and should all be striving to foster working environments free of bullies, whether in our hospitals, practices, professional organisations, or colleges.
Those of us involved in teaching medical students and registrars should be mindful of the powerful effects of role modelling on impressionable learners. The authors of a survey of medical students in the United States, along with others, believe that the use of aversive methods to make students learn to behave is likely to foster insensitive and punitive behaviours that are passed down from the teacher to learner, a transgenerational legacy that leads to future mistreatment of others by those who themselves have been mistreated. This undesirable result is compounded when these behaviours are adopted and directed
towards patients and colleagues.11 If we are to avoid perpetuating the harrowing experiences of bullying recently described in the BMJ
by a surgical trainee in the NHS,12 we need to lead by example. National Cancer Control Initiative, 1 Rathdowne Street, Carlton, Victoria 3053, Australia (firstname.lastname@example.org
) Monash University, Department of General Practice, 867 Centre Road, East Bentleigh, Victoria 3165, Australia (email@example.com
National Cancer Control Initiative, 1 Rathdowne Street, Carlton, Victoria 3053, Australia (firstname.lastname@example.org
Monash University, Department of General Practice, 867 Centre Road, East Bentleigh, Victoria 3165, Australia (email@example.com )
Competing interests: None declared.
© 2003 BMJ Publishing Group Ltd