Dr. Rubina Lone, MBBS, MD
Assistant Professor, Department of Microbiology
Skims Medical College/ hospital, Bemina Srinagar

Dr. Ajaz Lone, MBBS, Diploma Psychotherapy
Resident, Department of Psychiatry,
Skims Medical College/ hospital Bemina Srinagar

Dr. Abid Amin, MBBS., MD Paediatrics
Senior Resident,
Skims Medical College Bemina Srinagar

Dr.Shah Nawaz
Resident,
Sheri Kashmir Institute of Medical Sciences

Dr. Shabana Lone
Assistant Registrar
Al Rashid Medical Centre, Salmia Kuwait

Correspondence:
Dr. Rubina Lone, MBBS, MD
Assistant Professor, Department of Microbiology
Skims Medical College/ hospital, Bemina Srinagar
Email: dr.rubina.lone@gmail.com

Harassment at places that necessitate an unavoidable social interface has always been considered more of a civilization attribute than an adverse and abominable human behavioral pattern so much so that our reaction mechanisms to any kind of harassment are often finely-adjusted by this ubiquitous conformist mindset. If not disregarded as cynicism it can be said with a fair amount of leniency that bullying and its various forms have become more of an office-accessory now, engendering the whole gamut of interpersonal relationships at the work-place. As such it becomes imperative to study this unwholesome tendency in its various contexts given the profound impact it has on the productivity of the group activity.
Workplace bullying is a major source of stress; breakdown and malfunction in modern heath care systems. It is an important issue for the health services because of its potential impact on staff health, retention, and patient care.^[1,2] Growing literature has identified workplace bullying as a major occupational stressor among health professionals. A study carried out in an NHS community trust found that 1 in 3 staff reported being bullied in the UK.^[3] To understand the problem better, we investigated how commonly doctors in training experienced persistent and serious bullying, who were the sources of this behavior, and what action was taken to deal with it. Many junior doctors experience bullying during their training. There are even cases of juniors being physically abused, pushed around, verbally abused, and ignored. However, some forms of bullying are more insidious, such as threats over references. Part of the problem is that progress in the medical profession still works on a system of patronage and word of mouth.
Accusations of bullying have become much more common in medicine.^[3] This perhaps represents an increased perception and awareness rather than the rise in the abusive personalities in the health system.^[4] Various studies in different parts of the world have shown that junior doctors suffer high levels of mistreatment or bullying during training which increases with progression through medical school, spilling over into early training years.^[3,5]
There are many definitions of bullying. Following are examples of some of the definitions found in literature. According to Einharsen bullying emerges when one perceives to be on a receiving end of negative actions persistently over a period of time and finds oneself unable to defend himself against these actions.^[6] Raynor and Hoel have defined five bullying behaviors. These are; threat to personal status, threat to personal standing, isolation, overwork and destabilization.^[7]
It would appear from the above introduction that bullying is commonplace in health care providers and junior doctors are no exception to it; however the extent of this problem remains unknown in our health system as bullying amongst junior doctors and professionals has been studied only in developed countries and has received limited, if any, attention in India and other developing countries.^[8] In Kashmir, a Muslim majority province of India studying the issue of harassment amongst the junior doctors or any other professional group has so far been a totally forbidden domain given the varied connotations that such study might assume in wake of the apparent orthodoxy of Kashmiri society. But notwithstanding those taboos and superficial impressions, this questionnaire survey brought forth results in total contrast to the popular expectation but in total consonance with the presumption of the same being a contributory to the ailing health care system of the Kashmir valley. With the above background the aim of our study was to ascertain the prevalence of workplace bullying in junior doctors working in various hospitals of Kashmir, to assess its impact on professional and family life and to identify the common source of bullying. We carried out a questionnaire survey.

 

METHODS

A cross-sectional questionnaire survey was conducted among junior doctors in training (interns; junior residents, postgraduate students (PGs) and senior residents of different specialties working in various hospitals of the valley). A convenient sample of 96 subjects took part in the study. Standard written explanation of bullying^[7] was provided to the participants, who were advised to read it prior to filling in the actual questionnaire The data collected was anonymous and included age, gender, job grade and job satisfaction in addition to 25 specific questions regarding bullying, its source, frequency, its effects on home life and productivity of work and different types of bullying behaviors. Data were recorded and statistically analyzed wherever applicable.

The response rate was 61%: out of a total 157, 96 completed questionnaires were included in the study (11 questionnaires were incomplete and 41 were not returned and thus were not included in the study). As shown in Table 1, 45.8% (44) of the participants were interns, 33.3% (32) junior residents, 11.4% (11) postgraduate students and rest 9.5% (9) were senior residents. Half were males (48). Overall, 54 (56%) of the 96 junior doctors identified themselves as having been bullied in the past six months, irrespective of the group to which they belonged to and seventy-nine (82%) had witnessed the bullying of others. Female doctors reported significantly higher (p<0.005) rates of all the bullying behaviors as compared to their male counterparts (39% vs 17%). The proportion of subjects bullied was also significantly higher amongst individuals aged below 25 years (P <0.001) and men were more likely to report being bullied than women (5% vs. <1%). Table 2 summarizes the response to the individual questions for the whole group. Highest scores were for obstructive attitude of the paramedics and attempts to humiliate in front of your colleagues. 60% of the responders complained that bullying affected their performance and productivity at work while more than one third reported bullying affected their home life. Female doctors were found to have higher incidences of perceived adverse effect on their productivity and family life. Common bullies are identified in Table 3. Male and female junior doctors identified nursing staff and other paramedics as the commonest bullies. The other groups of bullies included seniors and administrative staff. Patients and their relatives were responsible for a small proportion of bullying. Most of the junior doctors were subjected to bullying by the paramedical personnel (P <0.0001). Irrespective of the group to which they belonged more than 95% of bullying went unreported. Nearly 62% of those bullied felt complaining would not make a difference, 24% were afraid of the consequences while the rest, 10%, were not sure how to complain.

Bullying is akin to an endemic disease that runs across borders and cultures. It is also prevalent amongst the medical community and is seen in professional, research, teaching and administrative fields.^[9] The prevalence of bullying in junior doctors working in various hospitals of Kashmir is 56%, which is similar to reports from India by Bairy et al.^[10] The study suggests that bullying could be a significant problem in the country. For various reasons, as seen in our study, bullying is generally under-reported. However, it is a matter of concern that less than 10% of subjects reported being bullied in contrast to 67% in the west.^[3] It is pertinent to note that even perceptions of bullying can have a negative impact on the overall climate and outcome of the workplace.^[10] Women were more likely than men to be bullied, and this finding is consistent with a study of university employees Bjorkvist et al.^[9] As far as the medical profession is concerned, women remain at a risk of sexual harassment by significant others, including patients, despite the power they acquire through medical training.^[12] In India a web-based survey found that incidents of workplace-related sexual harassment do exist and the victims were mostly young women seeking care in urban health facilities, PGs, field staff and contract employees.^[8] It is clear from the available evidence that bullying and harassment can have profoundly negative effects. Severe harassment and belittlement may be associated with higher rates of alcohol misuse, depression, and suicidal intent and with lower satisfaction with their chosen career as a doctor.^[13] The problem of bullying needs to be addressed in earnest. A few measures for tackling the issue are suggested: acknowledging existence of the problem could be the starting point. Next, anti-bullying policies need to be developed, disseminated and implemented in our hospitals. As of now no such policies have been enunciated. Information sessions could be used to increase the awareness of bullying as an organizational problem. Victims should be provided with support and access to dispute-resolution procedures.^[14] Measures like teaching the appropriate skills to those who deal with bullying, personal development of consultants or others who interact inappropriately, program for trainees to tackle bullying effectively and appropriate reward-punishment for the concerned.^[15] It is not easy to prevent bullying and harassment in the workplace. It requires people to moderate their behavior so that they become positive role models and demand considerable changes in institutional culture.
The negative impact that bullying and harassment have on the well being of students and doctors, overall morale in the medical workforce, and recruitment and retention in the profession demand our continuing efforts to resolve these problems. An educational approach to the problem of bullying has its place; however, it cannot be a substitute for punishing action. Needless to say it would take a lot of effort and time before this problem is controlled or eradicated. However if it is allowed to grow it will not only hinder the progress but also incapacitate the current health system. It is high time now to show zero tolerance and say no to bullying.

1. Firth-Cozens J. Interventions to improve physicians' well being and patient care. Soc Sci Med 2001; 215-22.
   
2. Hicks B. Time to stop bullying and intimidation. Hospital Medicine 2000; 61: 428-31.
   
3. Quine L. Workplace bullying in NHS community trust: staff questionnaire survey. BMJ 1999; 318: 228.
4. Paice E. Firth-Cozens J. Who's a bully then? BMJ 2003; 326: 127 -232.
5. Daugherty S, Baldwin D, Rowley B. Learning, satisfaction and mistreatment during medical internship. JAMA 1998; 279: 1194-1199.
   
6. Einharson S. Bullying and its relationship to work and environment quality: an exploratory study. Eur Work Org Psychol 1994; 4: 381-401.
   
7. Rayner C, Hoel H. A summary review of literature relating to work place bullying. J comm. Appl Soc Psychol 1997; 7: 181-91.
8. Ramanathan R, Sharma PS, Sukanya R, Saritha PV. Sexual harassment in the workplace: Lessons from a web based survey. Indian J Med Ethics 2005; 2:47-50.
9. Bjorkqvist K, Osterman K, HjeltBack M. Aggression among university employees. Aggressive Behavior 1994; 20:173-84.
   
10. Bairy KL, Thirumalaikolundusubramanian P, Sivagnanam G, Saraswathi S, Sachidananda A, Shalini A. Bullying among trainee doctors in Southern India: A questionnaire study J Post Grad Med 2007: 53: 87-90.
    
11. Poole E, Pogrebin M. Factors affecting the decision to remain in policing: A study of women officers. J Police Sci Admin 1988; 49-5512.
    
12. Phillips SP, Schneider MS. Sexual harassment of female doctors by patients. N Eng J Med 1993; 329:1936-9.
    
13. Frank E, Carrera JS, Stratton T, Bickel J, Nora LM. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ 2006 doi: 10.1136/bmj.38924. 722037.7C.
    
14. Barron O. Bullying at work. J Occup Health Safety 1998; 14:575-80.
    
15. Hicks B. how can a deanery win the battle against bullying? BMJ 2003; 326:S129.