What is bullying?

Trainees vary in the way they interpret behaviours of others in the workplace, with different thresholds for identifying a given behaviour as ‘bullying’. Furthermore, there may be a semantic context, whereby some individuals will label unwanted behaviours by staff that are suggestive of racial or gender discrimination as ‘racist or ‘sexist’ respectively, instead of ‘bullying’. Some sexual behaviour, such as uninvited requests for a date, or sexual remarks or looks, are not always viewed as harassment by male trainees.^{Reference Morgan and Porter14}

Although there needs to be a balance in the structure of instruments designed to collect data on bullying and harassment it may be preferable to include a broad range of behaviours under the umbrella of ‘bullying’ rather than having too narrow a focus, and also to enquire whether the trainees viewed those items as bullying or not. The Quine questionnaire is a comprehensive tool for evaluating bullying and harassment behaviour. The earlier (20-item) version did not include, as bullying, discrimination on the basis of race and gender, but these were added in the updated (21-item) version.^{Reference Quine1,Reference Quine12}

Qualitative data in the Australian study revealed that several psychiatric trainees viewed unfair criticism and humiliation as just a ‘normal ‘experience in training, rather than a form of bullying.^{Reference Kozlowska, Nunn and Cousens17} These experiences included being shouted at in the presence of others, being blamed for a patient suicide and being told that they were incompetent. Yet, ostensibly, these behaviours may be reasonably regarded as bullying in other contexts, and the trainees’ views may reflect either the Australian sociocultural context, or perhaps acclimatisation to prevalent bullying.

There is also the salience of the role of medical practitioners, the training programmes, health system and sociocultural milieu, without which bullying cannot be fully contextualised, and which differ considerably even across the studies included in the review (Pakistan, UK, Australia). For example, although Australia is an Anglophone country, its sociocultural characteristics are considerably different from the UK and from Pakistan, a South Asian country.

How do bullying rates in psychiatric training compare with those in other medical specialties?

The background levels of bullying in general are concerningly high in healthcare, and a recent international umbrella review found that physicians were the second most commonly affected group (after nurses), at a prevalence of 11.5–78.1%.^{Reference Colaprico, Addari and La Torre20} Overall prevalence of bullying across the healthcare profession varied by region, with the highest levels in Europe (at 26.4%) and lowest in Southeast Asia (5.3%).^{Reference Colaprico, Addari and La Torre20} This highlights the need for cultural reference points for bullying rates, even if these are from other medical specialties, to provide some health system and sociocultural context. One might speculate that the apparent disparity in bullying rates between Europe and Southeast Asia may be due, at least in part, to possible underreporting due to differing sociocultural contexts. A cross-sectional survey and interview study of workplace bullying in the UK's National Health Service (NHS) found that 20% of staff (doctors, dentists, nurses, allied health, technicians, administration) reported having been bullied by another staff member, and 43% reported having witnessed bullying, in the preceding 6 months.^{Reference Carter, Thompson, Crampton, Morrow, Burford and Gray21}

The relative rates of bullying experienced by 1852 cardiology trainees in Pakistan was assessed using the Negative Acts Questionnaire-Revised (NAQ-R), with bullying reported by 10.2% of males and 13.4% of females.^{Reference Rashid, Ullah, Satti, Malik, Iqbal and Mehmoodi22} The rate of bullying of cardiology physician trainees was 11% in a survey of 1358 respondents in the UK,^{Reference Camm, Joshi, Moore, Sinclair, Westwood and Greenwood23} with cardiology specialists (80%) and other medical specialists (70%) most commonly implicated in bullying. As a comparator for Australia, the rate of bullying in a surgery survey of 3516 not limited to trainees is very high, at 49.2%,^{Reference Crebbin, Campbell, Hillis and Watters24} and most perpetrators were male surgical specialists. Unfortunately, it appears that surgery has very high rates of bullying in the UK and Ireland (60% of 837 trainees) as well.^{Reference Clements, King, Nicholas, Burdall, Elsey and Bucknall25}

Australia has a national survey of medical practitioners attached to the medical board registration process, and this reports data as the Medical Training Survey.²⁶ In national survey data of Australian psychiatric trainees in 2020–2022, 22% reported personally experiencing bullying and harassment while 32% reported witnessing bullying and harassment, with similar rates for both of these in 2019–2021.^{Reference Wilkes, Munindradasa, Maguire, Anderson and Looi27} Australian physician and surgical trainees reported very similar rates, so this may well reflect the overall levels of bullying in the sociocultural milieu of Australian medical training.^{Reference Wilkes, Munindradasa, Maguire, Anderson and Looi27}

Who are the bullies?

The high proportion (73.3%) of perpetrators reported to be consultants in the Pakistan study may have a cultural context, as suggested by the study's authors.^{Reference Ahmer, Yousafzai, Siddiqi, Faruqui, Khan and Zuberi16} There is a strongly hierarchical aspect to the health system in Pakistan, with medical practitioners, especially those with a postgraduate qualification, being considered higher in status than nurses and allied health practitioners. There exists an overarching power gradient between consultant supervisors and trainees, and at the time of this Pakistan study (2007), supervisors could disrupt the career trajectory of the trainee by declaring that they were not ready to sit their postgraduate examination, with no appeals permitted in most regions of the country. The substantial level of bullying by peers in the study may possibly reflect the competitive training environment but may possibly also indicate a lack of solidarity among some of the trainee groups.

The lower but still substantial levels of bullying by senior doctors in the UK reported by psychiatric trainees may also have a cultural dimension. As the authors of the West Midlands study suggest, psychiatric training (and medical training more broadly) takes place in UK institutions which have, or have had, a very hierarchical operational structure, and traditionally teaching has employed intimidation and opprobrium, which may promote a culture of bullying and harassment.^{Reference Hoosen and Callaghan13} The authors point out that there may be cycles of mistreatment whereby those who were bullied go on to bully junior doctors when they themselves become senior clinicians.

Similarly, the reporting of Australian consultants’ demeaning behaviours towards their psychiatric trainees may relate to structural hierarchy.^{Reference Reddy and Kaplan15}

Measures of bullying used

There are challenges in standardising and measuring the magnitude and intensity of bullying behaviours. Two of the studies in this review used the Quine bullying questionnaire.^{Reference Hoosen and Callaghan13,Reference Ahmer, Yousafzai, Siddiqi, Faruqui, Khan and Zuberi16} This questionnaire was first used by Quine in 1999 when evaluating workplace bullying in an NHS community trust, and subsequently used by Quine and her colleagues to evaluate bullying among junior doctors, doctors undertaking research and postgraduate hospital dentists.^{Reference Quine12,Reference Steadman, Quine, Jack, Felix and Waumsley28} Despite a paper in our review stating that the questionnaire has been validated, we could not find any evidence of this.^{Reference Ahmer, Yousafzai, Siddiqi, Faruqui, Khan and Zuberi16} However, the 20 questions used in the questionnaire (first version) were based on a thorough exploration of the nature, form and contexts of bullying behaviours identified by an extensive literature review, including the six categories formulated by Rayner & Hoel, described above.^{Reference Rayner and Hoel29} The Quine bullying questionnaire simply asks respondents to indicate with a binary yes/no whether they had been persistently subjected to any of the 20 listed behaviours over the preceding 12 months.

A further two studies used their own ‘purpose-built’ questionnaires, which had not undergone evaluation of psychometric properties and therefore may contribute to some weakness and uncertainty in the reliability and validity of the findings.^{Reference Morgan and Porter14,Reference Reddy and Kaplan15}

The final study^{Reference Kozlowska, Nunn and Cousens17,Reference Kozlowska, Nunn and Cousens19} used a partially validated tool (the Training Impact Questionnaire). An initial draft questionnaire was revised after input by five fellow psychiatric trainees. This revised version was endorsed for face validity and comprehensiveness of content coverage by experienced researchers. The authors acknowledged the need for testing for discriminant validity and predictive validity for future research.

Although not used in any of the studies in this review, a widely used tool to assess workplace bullying is the Negative Acts Questionnaire-Revised (NAQ-R).^{Reference Einarsen, Hoel and Notelaers3} The NAQ-R has 22 items that assess the occurrence of bullying within the previous 6 months of work as experienced by the respondents. It has been used in the UK and abroad.^{Reference Einarsen, Hoel and Notelaers3,Reference Erwandi, Kadir and Lestari7} It has been shown to have sound psychometric reliability and validity. When a sample of 5288 UK employees was analysed the NAQ-R was found to have high internal stability and three underlying factors, consisting of personal bullying, work-related bullying and physically intimidating bullying. However, the NAQ-R was demonstrated also to function as a single factor measure.^{Reference Einarsen, Hoel and Notelaers3} Criterion validity was found when an external single item measure of perceived victimisation from bullying correlated highly with the total NAQ-R score as well as the scores on the three factors. Targets of bullying had significantly higher scores on all 22 items compared with non-targets.

Sequelae of bullying

There were no quantitative data from the review studies relating to sequelae of workplace bullying of psychiatric trainees. However, qualitative data in the Australian study showed reports, by trainees, of reduced self-confidence, distress, fear and feelings of uselessness.^{Reference Kozlowska, Nunn and Cousens17} It is unclear whether these consequences were transient or more enduring.

Studies of public health staff, more broadly, provide evidence of important associations with bullying, including reduced job satisfaction, higher stress levels, a greater likelihood of anxiety or depression, more likelihood of reporting wanting to leave work and increased amount of sick leave taken.^{Reference Quine1,Reference Quine12,Reference Kivimäki, Elovainio and Vahtera30} Although these may be a direct result of bullying, there are other possible contexts. Staff who have pre-existing anxiety or depression, or poor coping abilities, may have a lower threshold for labelling behaviours as bullying and be more likely to report them. Alternatively, staff who have pre-existing anxiety or depression may be targeted by bullies. There may also be an increased risk of cardiovascular disease associated with bullying, mediated through comfort eating leading to being overweight.^{Reference Kivimäki, Virtanen, Vartia, Elovainio, Vahtera and Keltikangas-Järvinen31} It should also be borne in mind that bullying behaviours, especially if reported to the medical board, may also do harm to the perpetrator, including loss of employment or de-registration, as well as reputational damage.

Reporting, seeking help and the path forward

Understanding the barriers to trainees reporting bullying, and ways of removing these barriers, are essential steps in the path forward. It is concerning that less than 50% of trainees in one study reported knowing who to contact when bullying occurs.^{Reference Hoosen and Callaghan13} Obstacles to reporting in a key study of bullying of UK NHS staff have been identified and include the belief that nothing would change, not wanting to be viewed as a troublemaker, the seniority of the perpetrator and uncertainty about how existing policies would be enacted and specific bullying allegations managed.^{Reference Carter, Thompson, Crampton, Morrow, Burford and Gray21} Psychiatry trainees may fear punitive repercussions from senior colleagues or managers/administrators as well as not being taken seriously or being labelled as having a ‘victim mentality’. This would be consistent with the qualitative data in the Australian study describing that trainees reported being ridiculed and their grievances related to bullying being ‘laughed off’.^{Reference Kozlowska, Nunn and Cousens17} The Australian study of surgical specialties, which included trainees, found that 44.7% of survey respondents indicated that they did not report bullying, so perhaps this may be common among Australian trainees.^{Reference Crebbin, Campbell, Hillis and Watters24}

The finding in the West Midlands study that foreign trainees were significantly less likely to take action when bullied raises concerns.^{Reference Hoosen and Callaghan13} As the authors of that study point out, this may be due to the overseas trainees deciding that the incentives for challenging and confronting the bullying behaviours were outweighed by the gains from remaining quiet or colluding with the perpetrator. These trainees may be loath to ‘upset the apple cart’ and risk alienating consultants who they may be relying on for a reference or endorsement of their continued training and associated visa issues. They may also feel judged by their peers, who they fear may wrongly attribute the issues to ‘acculturation’ factors. Furthermore, being in a foreign country away from their usual social supports may also contribute to reluctance to confront perpetrators of bullying.

Awareness and prevention of bullying are also key steps in the path forward. As revealed in the Pakistan study, some trainees who reported experiencing bullying behaviours over the preceding 12 months in the Quine questionnaire did not report being bullied when asked directly in the survey.^{Reference Ahmer, Yousafzai, Siddiqi, Faruqui, Khan and Zuberi16} Even more concerning was the finding in the Australian study that several trainees viewed clearly bullying behaviours as a normal experience of training. Therefore, awareness programmes should be part of trainee orientation processes, with regular booster sessions over the course of training. In light of the finding in the West Midlands study that less than half (46%) of respondents reported that they did not know who to contact if bullied, there should be clear, easily accessible anti-bullying policies, protocols and codes of conduct.^{Reference Hoosen and Callaghan13} Consultant psychiatrists need to be aware of their responsibility in preventing workplace bullying and the range of behaviours that trainees may perceive as bullying.

Trainees need to be made aware of these resources in combination with active implementation by management. Given that many trainees seem reluctant to report and pursue assertive action against bullying, management needs to adopt proactive approach, including clearly communicated guidelines for trainees, perhaps during orientation, and with reinforcement each year of training, outlining the steps that need to be taken if bullying occurs. A ‘zero-tolerance’ policy on bullying by staff should be adopted by health services, medical boards and psychiatric colleges. A broad framework includes documentation of the bullying, reporting, and support from, and discussion with, peers and members of medico-political organisations such as medical associations, colleges of psychiatrists and unions.^{Reference Looi, Allison and Bastiampillai32}

That the consequences of bullying can be devastating is highlighted by the previously cited study of the Australian surgical specialty, where 10.5–18.5% of those bullied left their jobs.^{Reference Crebbin, Campbell, Hillis and Watters24}

Further research is therefore required with larger, more methodologically robust studies, exploring the nature, intensity, amount and contexts of bullying of psychiatric trainees. Perhaps data on bullying of psychiatric trainees are being collected by mandatory feedback processes for deaneries/local training schemes and directors of training but, owing to its sensitive nature and implications, the information is accessible to only a select few.

Strengths and limitations

Limitations

There are many limitations to this review. It included only five studies informing on bullying of psychiatric trainees with primary data, and only one has been conducted within the past 10 years. The lack of recent studies is particularly important given the apparent shift that has occurred in the past 10–20 years regarding the (un)acceptability of bullying and sexual harassment within medical training, and in society more broadly. With the expansion of social media, and the MeToo movement (which originated in the context of sexual violence in the community), there may be increasing sharing of information on bullying, including how to deal with it. Furthermore, quality assessment indicated methodological weaknesses in the included studies (Table 2). The study designs in the papers were cross-sectional surveys with no comparator group (e.g. trainees in another faculty) and uncontrolled potential confounders, such as socioeconomic status and possible mental health problems of some trainees, which may make them more likely to report bullying (reporting bias). In some studies of bullying of junior doctors generally (not the studies in our review, which focused on psychiatric trainees), a mood dispositional dimension called negative affectivity has been controlled for, as people who are high in this item are more likely to report distress and grievances.^{Reference Quine12,Reference Quine33} However, this was not performed in the studies in our review. As cross-sectional surveys inviting voluntary participation from trainees, all studies in this review are subject to self-selection bias. Although two studies^{Reference Hoosen and Callaghan13,Reference Reddy and Kaplan15} in our systematic review included ethnic background and overseas doctors training in the UK as part of the sociodemographic data collected, the remainder did not. In addition, studies would have been enhanced if more training variables and occupational health variables had been included. These would have enabled a better exploration and analysis of possible predictors of bullying and adjustment for potential confounders. All studies lacked the employment of an instrument with demonstrated psychometric reliability and validity, such as the NAQ-R. In addition, the inclusion of a measure of psychological distress such as the Kessler Psychological Distress Scale (K10) would have been useful. Only one study explored outcomes when bullied trainees sought help and support.^{Reference Hoosen and Callaghan13} Possible recall bias is another limitation of these cross-sectional surveys.

Table 2 Quality assessment of studies

Quality assessment tool for quantitative studies (Effective Public Health Practice Project).

Implications for further research

There are a surprisingly small number of studies investigating workplace bullying among psychiatric trainees, in the context of a medical specialty that provides mental healthcare and is therefore focused on holistic approaches to health and well-being, especially considering that consultant psychiatrists are often primarily responsible for the apprenticeship and creation of positive learning environments for trainees.

Although the reviewed studies have methodological limitations, the available evidence indicates that there is a substantial level of bullying of psychiatric trainees, and limited help-seeking by trainees for such bullying. Unfortunately, these findings are similar to those for the broader medical profession.

Further research is required with larger, more methodologically robust studies, exploring the nature, intensity, amount and contexts of bullying among psychiatric trainees. Perhaps data on bullying of psychiatric trainees are being collected by mandatory feedback processes for deaneries/local training schemes and directors of training but owing to its sensitive nature and implications, the information is accessible to only a select few. So, peer-reviewed published research is required to better ascertain the nature and extent of bullying across the profession, including in psychiatric specialist training, worldwide. Such research should include the use of standardised self-assessment surveys, based on agreed definitions of bullying, to allow for comparability of measurements, for example the Negative Acts Questionnaire or similar with local adaptations for language and context. However, to have real-world utility, any further studies should also usefully describe the psychiatric training programme and, at least briefly, the health system and sociocultural context in order to understand whether the findings are relevant to different contexts.

Currently, international healthcare workplace staffing shortages from the sequelae of the pandemic compound pre-existing workforce issues.^{Reference Looi, Allison, Bastiampillai, Kisely and Robson34} In this context, understanding how bullying may be occurring in psychiatric training is necessary to prevent harm and hopefully stem bullying-mediated exits from the profession.