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Department of Surgery, University of Southern California, Los Angeles, California; LACUSC Medical
*
Center, Los Angeles, California; and Department of Surgery, University of Nebraska Medical Center,
Omaha, Nebraska
OBJECTIVE: Workplace bullying is at the forefront of social of recommendations or orders by nurses occurs on a daily,
behavior research, garnering signicant media attention. weekly, or monthly basis for 30.2% of residents (work-
Most of the medical research has addressed bullying of related bullying). The most frequent person-related bullying
nurses by physicians and demonstrates that patient care and act is ignoring the resident when they approach or reacting
outcomes may suffer. The intent of this study was to in a hostile manner (18.0%), followed by ignoring or
determine if general surgery residents are bullied by nurses. excluding the resident (17.1%).
DESIGN: A survey instrument previously validated (Neg- CONCLUSIONS: Workplace bullying of general surgery
ative Acts QuestionnaireRevised) to evaluate for work- residents by nurses is prominent. Future research is needed
place bullying was modied to reect the resident-nurse to determine the toll on the residents well-being and
relationship. After institutional review board approval, the patient outcomes. ( J Surg 71:e149-e154. J C 2014 Associa-
piloted online survey was sent to general surgery program tion of Program Directors in Surgery. Published by Elsevier
directors to forward to general surgery residents. Demo- Inc. All rights reserved.)
graphic data are presented as percentages, and for negative
KEY WORDS: workplace bullying, general surgery resi-
acts, percentages of daily, weekly, and monthly frequencies
dents, nurses
are combined.
COMPETENCIES: Professionalism, Interpersonal and
SETTING: Allopathic general surgery residencies in the
Communication Skills, Patient Care
United States.
PARTICIPANTS: General surgery residents.
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 e149
Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.08.003
were nurses and men the physicians with clearly dened roles.7 Surveymonkey.com) to their residents. The survey was
Much of the bullying literature with regard to American health administered during the nal 2 weeks of October. All
care has been published in the nursing literature. Numerous survey answers were condential; no individual resident
nursing organizations lobby against workplace bullying of was contacted, and the program directors were used to
nurses by issuing position statements, calling for dialogue, ensure condentiality. Further, 2 generalized reminders
and petitioning for zero tolerance policies.8 were sent out to the program directors asking them to
With respect to physician trainees, the Association of remind their residents to complete the survey.
American Medical Colleges advocates for medical students Data collected included demographics and responses to
and annually assesses bullying on the Medical School the 22 survey questions. The size of the residency programs
Graduation Questionnaire.9 Unfortunately, data about the was categorized based on the number of residents per year
bullying of residents are not formally gathered, and the
TABLE 1. Demographics
topic is rarely addressed.10 Thus, we sought to describe the
workplace bullying of general surgery residents: a group of Resident gender
learners with increased responsibility in a discipline where Male 55.1%
bullying has previously been reported at higher levels.11,12 Female 40.7%
Resident clinical year
Specically, we questioned whether general surgery resi- PGY 1 27.0%
dents are bullied by nurses based on the unequal balance of PGY 2 18.8%
medical knowledge on the physicians part, and experience PGY 3 15.3%
and tenure of nurses who contribute to the residents PGY 4 13.5%
education. PGY 5 11.7%
Research year 9.5%
Resident race
White 69.5%
METHODS African American 3.5%
Hispanic 5.8%
This study was approved by the Biomedical Institutional Asian 11.9%
Review Board at the University of Southern California. Other 4.9%
Resident sexual orientation
Participation in the survey was voluntary and without Heterosexual 92.9%
compensation. The Negative Acts QuestionnaireRevised Homosexual 1.8%
is a previously validated instrument that is utilized by Bisexual 0.7%
various organizations to survey workplace bullying.13 Other 0.2%
It targets the persistent exposure to interpersonal aggression Played team sport (high school or college)
Yes 77.9%
and mistreatment from colleagues, superiors, or subordi- No 17.9%
nates.13 The Negative Acts QuestionnaireRevised was Resident in military
ideal for this study, given its brevity, reliability, adaptability Yes 4.9%
to many institutional settings, and development specically No 90.9%
for Anglo-American culture.13 The 22 questions were Nurse in residents immediate family
Yes 24.8%
tailored to reect the general surgery resident and nurse No 71.0%
relationship. Additionally, demographic questions were Surgeon in residents immediate family
included before the instrument questions. Yes 10.2%
No 85.6%
Type of program
Instrument Validity University 71.9%
Community 23.5%
The validity of the survey tool was conrmed by piloting Military 2.2%
with 15 obstetric/gynecological residents. We felt this was a Location of program
reasonable comparison, given the similarity of a surgical Northeast 4.6%
East 15.7%
background. Following completion of the pilot survey, Southeast 15.9%
1 investigator discussed the survey tool with the pilot South 11.3%
participants to ensure that the survey questions and answers Midwest 27.7%
were understandable. Southwest 5.1%
West 17.3%
Small (2-4 residents/y) 28.8%
Survey Methodology Medium (5-7 residents/y) 44.9%
Large (Z8 residents/y) 23.9%
A personal invitation e-mail was sent to all allopathic general Private hospital 21.2%
surgery program directors. They were asked to electronically County hospital 19.5%
distribute the link to the online survey (designed using Combined or hospitals of both type 35.6%
therapists and other support staff,19 but in revisiting the behavior.22 Residents too can be distracted, have difculty
topic 5 years later, the medical director of JCAHO stated it concentrating, not want to go to a bedside and write an
is the behavior of the doctors which most often causes order, or ask the nurse a clinical question when facing a
problems.20 Interestingly, the rst reference of the JCAHO negative, aggressive nurse. It is common for general surgery
Sentinel Event Alert and the revisiting commentary dem- residents to be highly involved in patient care, taking in-
onstrate 68% and 65% of respondents, respectively, had house or home calls. They are often the rst responders,
witnessed disruptive behavior by nurses.21,22 Specically, answering questions, writing orders, making plans, and
48% of physicians had witnessed nurses exhibiting disrup- intervening in patient care. If general surgery residents are
tive behavior, and 28% of all respondents felt disruptive experiencing workplace bullying at the hands of nurses, then
behaviors by any staff occurred most often in general avoiding interaction with those individuals would be a likely
surgery.22 Our ndings demonstrate that residents had and understandable reaction. What effect this discord has
experienced each of the 22 negative acts at the hands of on patient safety is unknown and may be an area for future
nurses with frequencies ranging from 11.5% (physical research.
violence) to 82.5% (ignored recommendations or orders). The effects of workplace bullying on the victim have been
Excluding physical violence, each of the remaining 21 documented and include health issues (hypertension,
negative acts occurred on a daily to monthly basis for insomnia, and gastrointestinal problems) and mental health
1.3% to 30.2% of respondents. issues (posttraumatic stress disorder, depression, and suicidal
Rosenstein and ODaniel22 further examined the clinical ideation) extensively documented by Namie.23 The suicide
effect of disruptive behaviors that may contribute to adverse rate of male physicians is 40% higher than in the general
patient events: 83% of respondents felt that disruptive male population and that of female physicians is 130%
behavior caused loss of concentration, 89% felt that it higher than in the general female population.24 Moreover,
reduced team collaboration, 87% felt that it reduced physicians are more likely to be effective at such attempts.24
information transfer, 91% felt that it reduced communica- Residents also have a higher depression and suicide rate than
tion, and 99% felt that it impaired the nurse or physician. observed in the general population.25 Residents who were
Nearly 1 of 5 respondents were aware of specic adverse sexually harassed at a Canadian hospital experienced
events that occurred as a direct result of disruptive embarrassment (24.0%), anger (23.4%), frustration