Bullying in medicine

Last updated

Bullying in the medical profession is common, particularly of student or trainee physicians. It is thought that this is at least in part an outcome of conservative traditional hierarchical structures and teaching methods in the medical profession which may result in a bullying cycle.

Contents

According to Field, people with Type A personality are attracted to highly educated professions such as medicine and law, both by the pride of overachievement and by the opportunities to exercise authority over others. Personal egotism, reinforced by successes in career development and increased social status, can lead to power harassment towards vulnerable clients, colleagues and students.

While the stereotype of a victim as a weak person who somehow deserves to be bullied is salient, there is growing evidence that bullies, who are often driven by jealousy and envy, pick on the highest performing students, whose mere presence is sufficient to make the bully feel insecure. The victim are usually academic high achievers and are likely to have been top of the class throughout their school years. As medical students have to compete against each other, this can make certain trainee doctors eager to stand out from the crowd, and some use underhanded techniques to gain more recognition.

The rampant problem of medical student mistreatment and bullying was systematically studied and reported in a 1990 JAMA study by pediatrician Henry K. Silver which found that 46.4 percent of students at one medical school had been abused at some point during medical school; by the time they were seniors, that number was 80.6 percent. [1]

In a 2002 test, 594 BMA members were randomly selected to complete a bullying survey, and 220 of the 594 junior doctors reported having been bullied in the previous year. This survey reported no variance in job grade or age. [2]

Psychology

Threats (of exposure of inadequacy) must be ruthlessly controlled and subjugated. [3] Psychological models such as transference and projection have been proposed to explain such behaviors, wherein the bully's sense of personal inadequacy is projected or transferred to a victim; through making others feel inadequate and subordinate, the bully thus vindicates their own sense of inferiority.

Displacement is another defense mechanism that can explain the propensity of many medical educators to bully students, and may operate subconsciously. [4] Displacement entails the redirection of an impulse (usually aggression) onto a powerless substitute target. [5] The target can be a person or an object that can serve as a symbolic substitute. [6] Displacement can operate in chain-reactions, wherein people unwittingly become at once victims and perpetrators of displacement. [7] For example, a resident physician may be undergoing stress with her patients or at home, but cannot express these feelings toward patients or toward her family members, so she channels these negative emotions toward vulnerable students in the form of intimidation, control or subjugation. [8] The student then acts brashly toward a patient, channeling reactive emotions which cannot be directed back to the resident physician onto more vulnerable subjects. [8]

A review found that there were 5 main drivers of bullying and unprofessional behaviours in healthcare: 1. disempowered staff who feel undervalued; 2. harmful workplace processes and cultures (high job demands because of understaffing, for instance); 3. a lack of team cohesion and support, which can be caused by shift working; 4. reduced ability to speak up; 5. managers who lack awareness or recognition of unprofessional behaviours, and take no action. [9] [10]

Beyond its ramifications for victims, disrespect and bullying in medicine is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. [11] [12] [9] [10]

Bullying cycle

Medical training usually takes place in institutions that have a highly structured hierarchical system, and has traditionally involved teaching by intimidation and humiliation.[ citation needed ] Such practices may foster a culture of bullying and the setting up of a cycle of bullying, analogous to other cycles of abuse in which those who experience it go on to abuse others when they become more senior. Medical doctors are increasingly reporting to the British Medical Association that they are being bullied, often by older and more senior colleagues, many of whom were badly treated themselves when more junior. [13]

Physician Jonathan Belsey relates in an emblematic narrative published in AMA Virtual Mentor entitled Teaching By Humiliation that "however well you presented the case, somewhere along the line you would trip up and give the predatory professor his opportunity to expose your inadequacies. Sometimes it would be your lack of medical knowledge; sometimes the question that you failed to ask the patient that would have revealed the root of the problem, or sometimes your ineptitude at eliciting the required clinical signs. On one memorable occasion, when I had appeared to cover all the bases clinically, the professor turned to me and berated me for attending his ward round wearing a plaid shirt that was clearly inappropriate for an aspiring doctor." [14]

Impact

Bullying can significantly decrease job satisfaction and increase job-induced stress; it also leads to low self-confidence, depression, anxiety and a desire to leave employment. [3] [15] Bullying contributes to high rates of staff turnover, high rates of sickness absence, impaired performance, lower productivity, poor team spirit and loss of trained staff. [3] This has implications for the recruitment and retention of medical staff.

Chronic and current bullying are associated with substantially worse health, [16] according to research by Laura M. Bogart, associate professor of pediatrics at Harvard Medical School.

Studies have consistently shown that physicians have had the highest depression and suicide rates compared to people in many other lines of work—for suicide, 40% higher for male physicians and 130% higher for female physicians. [17] [18] [19] Research has traced the beginning of this difference to the years spent in medical school. [20] Students enter medical school with mental health profiles similar to those of their peers but end up experiencing depression, burnout, suicidal ideation and other mental illnesses at much higher rates. [21] [22] Despite better access to health care, they are more likely to cope by resorting to dysfunctional and self-injurious behaviors, and are less likely to receive the right care or even recognize that they need some kind of intervention.

Exposure to bullying and intimidation during formative years of medical training has been found to contribute to these consequences. Fear of stigmatisation among medical students was the subject of a study in JAMA by Thomas Schwenk and colleagues at the University of Michigan's Department of Family Medicine, USA. 53% of medical students who reported high levels of depressive symptoms were worried that revealing their illness would be risky for their careers and 62% said asking for help would mean their coping skills were inadequate, according to the study published in September 2010. "Medical students are under extraordinary demands. They feel they are making life and death decisions and that they can never be wrong. There is such tremendous pressure to be perfect that any sense of falling short makes them very anxious", says Schwenk. [23]

Types

Medical students

Medical students, perhaps being vulnerable because of their relatively low status in health care settings, may experience verbal abuse, humiliation and harassment (nonsexual or sexual). Discrimination based on gender and race are less common. [24]

In one study, around 35% of medical students reported having been bullied. Around one in four of the 1,000 students questioned said they had been bullied by a medical doctor. Furthermore, bullying has been known to occur among medical students. Manifestations of bullying include: [25]

One study showed that the medical faculty was the faculty in which students were most commonly mistreated. [28]

Bullying extends to postgraduate students. [29] [30]

Medical students are increasingly involved in scientific research, but as early career researchers, they are particularly vulnerable to exploitation and mistreatment. Toxic research cultures are highly detrimental, manifesting in unethical practices and abuse of power by more senior researchers. These environments foster undue credit claims, coercive behavior, and a competitive atmosphere that prioritizes personal gain over collaborative and ethical conduct. Such cultures, driven by pressures to publish and secure funding, undermine the well-being and professional development of junior researchers, perpetuating a cycle of mistreatment and ethical compromise. [31]

Junior (trainee) physicians

In a UK study, 37% of junior doctors reported being bullied in the previous year and 84% had experienced at least one bullying incident. Black and Asian physicians were more likely to be bullied than other physicians. Women were more likely to be bullied than men. [2]

Trainee physicians who feel threatened in the clinical workplace develop less effectively and are less likely to ask for advice or help when they need it. [32] Persistent destructive criticism, sarcastic comments and humiliation in front of colleagues will cause all but the most resilient of trainees to lose confidence in themselves. [33]

Consultants who feel burnt out and alienated may take their disaffection out on junior colleagues. [33]

The farewell interview from Sir Ian Kennedy (Chair of the Healthcare Commission) caused significant media interest following his statement that bullying is a 'corrosive' problem that the NHS must address.[ citation needed ]

Psychiatry

Psychiatric trainees experience rates of bullying at least as high as other medical students. In a survey of psychiatric trainees in the West Midlands, 47% had experienced bullying within the last year with even higher percentages amongst ethnic minorities and females. Qualified psychiatrists are not themselves required to be psychiatrically assessed. [34] [35]

Nursing

Nurses experience bullying quite frequently. [36] [37] It is thought that relational aggression (psychological aspects of bullying such as gossiping and intimidation) are commonplace. Relational aggression has been studied among girls but not so much among adult women. [38]

Speaking of many doctors' predilection for bullying nurses, Theresa Brown writes: [39]

...the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.

Sir Lancelot Spratt, a character played by actor James Robertson Justice in the film series Doctor in the House , is often referenced as the archetypal arrogant bullying doctor ruling by fear. The film series also demonstrates bullying of student doctors by other doctors and the nursing matron.

In the American sitcom Scrubs , Dr. Cox uses intimidation and sarcasm as methods of tormenting the interns and expressing his dislike towards them and their company.

See also

Related Research Articles

Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ... [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research." The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.

A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care provider.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailments.

Medical slang is the use of acronyms and informal terminology to describe patients, other healthcare personnel and medical concepts. Some terms are pejorative. In English, medical slang has entered popular culture via television hospital and forensic science dramas such as ER, House M.D., NCIS, Scrubs, and Grey's Anatomy, and through fiction, in books such as The House of God by Samuel Shem, Bodies by Jed Mercurio, and A Case of Need by Jeffery Hudson

Medical resident work hours refers to the shifts worked by medical interns and residents during their medical residency.

Workplace bullying is a persistent pattern of mistreatment from others in the workplace that causes either physical or emotional harm. It includes verbal, nonverbal, psychological, and physical abuse, as well as humiliation. This type of workplace aggression is particularly difficult because, unlike typical school bullies, workplace bullies often operate within the established rules and policies of both their organization and society. In most cases, workplace bullying is reported as being carried out by someone who is in a position of authority over the victim. However, bullies can also be peers or subordinates. When subordinates participate in bullying, this is referred to as ‘upwards bullying.’ The least visible form of workplace bullying involves upwards bullying where bullying tactics are manipulated and applied against a superior, often for strategically motivated outcomes.

An e-patient is a health consumer who participates fully in their own medical care, primarily by gathering information about medical conditions that impact them and their families, using the Internet and other digital tools. The term encompasses those who seek guidance for their own ailments, and the friends and family members who research on their behalf. E-patients report two effects of their health research: "better health information and services, and different, but not always better, relationships with their doctors."

David Lawrence Sackett was an American-Canadian physician and a pioneer in evidence-based medicine. He is known as one of the fathers of Evidence-Based Medicine. He founded the first department of clinical epidemiology in Canada at McMaster University, and the Oxford Centre for Evidence-Based Medicine. He is well known for his textbooks Clinical Epidemiology and Evidence-Based Medicine.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

The doctor–patient relationship is a central part of health care and the practice of medicine. A doctor–patient relationship is formed when a doctor attends to a patient's medical needs and is usually through consent. This relationship is built on trust, respect, communication, and a common understanding of both the doctor and patients' sides. The trust aspect of this relationship goes is mutual: the doctor trusts the patient to reveal any information that may be relevant to the case, and in turn, the patient trusts the doctor to respect their privacy and not disclose this information to outside parties.

<span class="mw-page-title-main">Controversies related to ME/CFS</span>

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is an illness with a history of controversy. Although it is classified as an organic disease by a majority of researchers, it was historically assumed to be psychosocial, an opinion still held among many physicians. The pathophysiology of ME/CFS remains unclear, there exist many competing diagnostic criteria, and some proposed treatments are controversial. There is a lack of education and accurate information about the condition among a significant number of medical practitioners, which has led to substantiated accusations of patient neglect and harm.

<span class="mw-page-title-main">Estimates of sexual violence</span>

Estimates of sexual violence are surveys of victims of sexual violence crime that have been undertaken to estimate the prevalence of sexual violence. The prevalence of sexual violence differs from the reported sexual violence statistics according to the law enforcement agencies due to the dark figure of crime and under-reporting of crime. The surveys use a common methodology to aid comparability.

Patient abuse or patient neglect is any action or failure to act which causes unreasonable suffering, misery or harm to the patient. Elder abuse is classified as patient abuse of those older than 60 and forms a large proportion of patient abuse.

Workplace harassment is the belittling or threatening behavior directed at an individual worker or a group of workers.

The nursing organization workplace has been identified as one in which workplace bullying occurs quite frequently. It is thought that relational aggression are relevant. Relational aggression has been studied amongst girls but rarely amongst adult women. According to a finding, 74% of the nurses, 100% of the anesthetists, and 80% of surgical technologists have experienced or witnessed uncivil behaviors like bullying by nursing faculty. There have been many incidents that have occurred throughout the past couple of years. OSHA, which stands for "Occupational Safety and Health Administration" stated that from 2011 to 2013, the United States healthcare workers experienced 15,000 to 20,000 significant injuries while in the workplace.

Bullying in academia is a form of workplace bullying which takes place at institutions of higher education, such as colleges and universities in a wide range of actions. It is believed to be common, although has not received as much attention from researchers as bullying in some other contexts. Academia is highly competitive and has a well defined hierarchy, with junior staff being particularly vulnerable. Although most universities have policies on workplace bullying, individual campuses develop and implement their own protocols. This often leaves victims with no recourse.

<span class="mw-page-title-main">Choosing Wisely</span> U.S.-based educational campaign

Choosing Wisely is a United States–based health educational campaign, led by the ABIM Foundation, about unnecessary health care.

Dinesh Kumar Makhan Lal Bhugra is a professor of mental health and diversity at the Institute of Psychiatry at King's College London. He is an honorary consultant psychiatrist at the South London and Maudsley NHS Foundation Trust and is former president of the Royal College of Psychiatrists. Bhugra was the president of the World Psychiatric Association (WPA) between 2014 and 2017 and the President of the British Medical Association in 2018-2019.

<span class="mw-page-title-main">Health information on the Internet</span>

Health information on the Internet refers to all health-related information communicated through or available on the Internet.

<span class="mw-page-title-main">Gender discrimination in the medical professions</span> Gender discrimination against female clinicians within the health profession

Gender discrimination in health professions refers to the entire culture of bias against female clinicians, expressed verbally through derogatory and aggressive comments, lower pay and other forms of discriminatory actions from predominantly male peers. These women face difficulties in their work environment as a result of a largely male dominated positions of power within the medical field as well as initial biases presented in the hiring process, but not limited to promotions.

References

  1. ↑ "VM – To Bully and Be Bullied: Harassment and Mistreatment in Medical Education, Mar 14 ... Virtual Mentor". virtualmentor.ama-assn.org. 2014-03-01. Archived from the original on 2014-03-13. Retrieved 2015-02-09.
  2. 1 2 Quine, L. (13 April 2002). "Workplace bullying in junior doctors: questionnaire survey". BMJ. 324 (7342): 878–879. doi:10.1136/bmj.324.7342.878. PMC   101400 . PMID   11950736.
  3. 1 2 3 Field, T. (2002). "Bullying in medicine". BMJ. 324 (7340): 786a–786. doi:10.1136/bmj.324.7340.786/a. PMC   1122715 . PMID   11923166.
  4. ↑ Salin, Denise (22 April 2016). "Ways of Explaining Workplace Bullying: A Review of Enabling, Motivating and Precipitating Structures and Processes in the Work Environment". Human Relations. 56 (10): 1213–1232. doi:10.1177/00187267035610003. hdl: 10227/283 . S2CID   55963468.
  5. ↑ Ahmed, Eliza (2006). "Understanding bullying from a shame management perspective: Findings from a three-year follow-up study" (PDF). Educational and Child Psychology. 23 (2): 25–39. doi:10.53841/bpsecp.2006.23.2.25. S2CID   147067476.
  6. ↑ "www.arimhe.com/uploaded/abstractbook.4th-worldwide-conference.pdf#page=25" (PDF). arimhe.com. Retrieved 2015-02-09.
  7. ↑ Einarsen, Stale; Hoel, Helge; Zapf, Dieter; Cooper, Cary (22 September 2010). Bullying and Harassment in the Workplace: Developments in Theory, Research, and Practice (Second ed.). CRC Press. ISBN   9781439804902 . Retrieved 2 November 2016– via Google Books.
  8. 1 2 Einarsen, Ståle (2000). "Harassment and bullying at work: A review of the scandinavian approach". Aggression and Violent Behavior. 5 (4): 379–401. doi:10.1016/S1359-1789(98)00043-3.
  9. 1 2 Aunger, Justin Avery; Maben, Jill; Abrams, Ruth; Wright, Judy M.; Mannion, Russell; Pearson, Mark; Jones, Aled; Westbrook, Johanna I. (2023-11-30). "Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review". BMC Health Services Research. 23 (1): 1326. doi: 10.1186/s12913-023-10291-3 . ISSN   1472-6963. PMC   10687856 . PMID   38037093.
  10. 1 2 "What drives unprofessional behaviour in healthcare?". NIHR Evidence. 5 November 2024.
  11. ↑ Leape, Lucian L.; Shore, Miles F.; Dienstag, Jules L.; Mayer, Robert J.; Edgman-Levitan, Susan; Meyer, Gregg S.; Healy, Gerald B. (July 2012). "Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians". Academic Medicine. 87 (7): 845–852. doi: 10.1097/ACM.0b013e318258338d . PMID   22622217.
  12. ↑ Anderson, Jim (April 2013). "Can "pimping" kill? The potential effect of disrespectful behavior on patient safety". Journal of the American Academy of Physician Assistants. 26 (4): 53–56. doi: 10.1097/01720610-201304000-00014 . PMID   23610843. S2CID   41937451.
  13. ↑ Williams K (1998) Stress linked to bullying. BMA News Review, April 18
  14. ↑ "VM – Teaching by Humiliation—Why It Should Change, Mar 14 ... Virtual Mentor". virtualmentor.ama-assn.org. 2014-03-01. Archived from the original on 2014-03-13. Retrieved 2015-02-09.
  15. ↑ Björkqvist, K (2001). "Social defeat as a stressor in humans". Physiology & Behavior. 73 (3): 435–42. doi:10.1016/S0031-9384(01)00490-5. PMID   11438372. S2CID   45769585.
  16. ↑ Bogart, Laura M.; Elliott, Marc N.; Klein, David J.; Tortolero, Susan R.; Mrug, Sylvie; Peskin, Melissa F.; Davies, Susan L.; Schink, Elizabeth T.; Schuster, Mark A. (17 February 2014). "Peer Victimization in Fifth Grade and Health in Tenth Grade". Pediatrics. 133 (3): 440–447. doi:10.1542/peds.2013-3510. PMC   4530298 . PMID   24534401.
  17. ↑ Rotenstein, Lisa S.; Ramos, Marco A.; Torre, Matthew; Segal, J. Bradley; Peluso, Michael J.; Guille, Constance; Sen, Srijan; Mata, Douglas A. (2016-12-06). "Prevalence of Depression, Depressive Symptoms, and Suicidal Ideation Among Medical Students: A Systematic Review and Meta-Analysis". JAMA. 316 (21): 2214–2236. doi:10.1001/jama.2016.17324. ISSN   1538-3598. PMC   5613659 . PMID   27923088.
  18. ↑ Mata, Douglas A.; Ramos, Marco A.; Bansal, Narinder; Khan, Rida; Guille, Constance; Di Angelantonio, Emanuele; Sen, Srijan (8 December 2015). "Prevalence of Depression and Depressive Symptoms Among Resident Physicians". JAMA. 314 (22): 2373–83. doi:10.1001/jama.2015.15845. PMC   4866499 . PMID   26647259.
  19. ↑ Chen, Pauline W. (2010-10-07). "The New York Times". The New York Times. Retrieved 2015-02-09.
  20. ↑ Hawton, K. (2000). "Doctors who kill themselves: a study of the methods used for suicide | QJM: An International Journal of Medicine". QJM. 93 (6). qjmed.oxfordjournals.org: 351–357. doi: 10.1093/qjmed/93.6.351 . PMID   10873184 . Retrieved 2015-02-09.
  21. ↑ "The occupation with the highest suicide rate | Psychology Today". psychologytoday.com. Retrieved 2015-02-09.
  22. ↑ Rotenstein, Lisa S.; Torre, Matthew; Ramos, Marco A.; Rosales, Rachael C.; Guille, Constance; Sen, Srijan; Mata, Douglas A. (September 18, 2018). "Prevalence of Burnout Among Physicians: A Systematic Review". JAMA. 320 (11): 1131–1150. doi:10.1001/jama.2018.12777. ISSN   1538-3598. PMC   6233645 . PMID   30326495.
  23. ↑ Devi, Sharmila (2011). "Doctors in distress". The Lancet. 377 (9764): 454–455. doi:10.1016/S0140-6736(11)60145-1. PMID   21300592. S2CID   36183787 . Retrieved 2015-02-09.
  24. ↑ Coverdale, J. H.; Balon, R.; Roberts, L. W. (2009). "Mistreatment of Trainees: Verbal Abuse and Other Bullying Behaviors". Academic Psychiatry. 33 (4): 269–73. doi:10.1176/appi.ap.33.4.269. PMID   19690101. S2CID   26914506.
  25. ↑ Curtis P Medical students complain of bullying The Guardian 4 May 2005
  26. ↑ "VM – Legacy Admissions in Medical School, Dec 12 ... Virtual Mentor". virtualmentor.ama-assn.org. 2012-12-01. Archived from the original on 2014-03-07. Retrieved 2015-02-09.
  27. ↑ "Connections to University can affect admissions decision | Stanford Daily". stanforddaily.com. 2013-03-13. Retrieved 2015-02-09.
  28. ↑ Rautio, Arja; Sunnari, Vappu; Nuutinen, Matti; Laitala, Marja (2005). "Mistreatment of university students most common during medical studies". BMC Medical Education. 5: 36. doi: 10.1186/1472-6920-5-36 . PMC   1285362 . PMID   16232310.
  29. ↑ Stebbing, J; Mandalia, S; Portsmouth, S; Leonard, P; Crane, J; Bower, M; Earl, H; Quine, L (2004). "A questionnaire survey of stress and bullying in doctors undertaking research". Postgraduate Medical Journal. 80 (940): 93–6. doi:10.1136/pmj.2003.009001. PMC   1742926 . PMID   14970297.
  30. ↑ Bairy, KL; Thirumalaikolundusubramanian, P; Sivagnanam, G; Saraswathi, S; Sachidananda, A; Shalini, A (2007). "Bullying among trainee doctors in Southern India: A questionnaire study". Journal of Postgraduate Medicine. 53 (2): 87–90. doi: 10.4103/0022-3859.32206 . hdl: 1807/52048 . PMID   17495372.
  31. ↑ Rajakumar, Hamrish Kumar; Gaman, Mihnea-Alexandru; Puyana, Juan C.; Bonilla-Escobar, Francisco J. (2024-07-09). "Transforming Toxic Research Cultures: Protecting the Future of Medical Students and Early Career Researchers – Part I". International Journal of Medical Students. 12 (2): 128–132. doi: 10.5195/ijms.2024.2763 . ISSN   2076-6327.
  32. ↑ Israël, E; Louwette, R; Lambotte, C (1975). "Two familial cases of congenital erythroderma ichthyosiforme". Revue Médicale de Liège. 30 (13): 439–44. PMID   1096266.
  33. 1 2 Paice E, Smith D (2009). "Bullying of trainee doctors is a patient safety issue". The Clinical Teacher. 6: 13–7. doi:10.1111/j.1743-498x.2008.00251.x. S2CID   71726099.
  34. ↑ Hoosen, I. A. (2004). "A survey of workplace bullying of psychiatric trainees in the West Midlands". Psychiatric Bulletin. 28 (6): 225–7. doi: 10.1192/pb.28.6.225 .
  35. ↑ Gadit AA Bullying in psychiatry must stop – Clinical Psychiatry News, May, 2007
  36. ↑ Hutchinson, M; Wilkes, L; Vickers, M; Jackson, D (2008). "The development and validation of a bullying inventory for the nursing workplace". Nurse Researcher. 15 (2): 19–29. doi:10.7748/nr2008.01.15.2.19.c6326. PMID   18283759.
  37. ↑ Porter-O'grady, T (2008). "Transforming work environments. Interview by Diane E Scott and Amanda Rosenkranz". The American Nurse. 40 (2): 7. PMID   18494401.
  38. ↑ Dellasega, Cheryl A. (2009). "Bullying among nurses". The American Journal of Nursing. 109 (1): 52–8. doi:10.1097/01.NAJ.0000344039.11651.08. PMID   19112267.
  39. ↑ Brown, Theresa (2011-05-07). "Physician Heel Thyself". The New York Times.

Further reading

This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.