Bullying and toxic workplace culture in the ICU

This chapter is directly relevant to Section 2.1.1 of the CICM Second Part General Exam Syllabus (First Edition), which specifically lists “workplace culture e.g., burnout, fatigue (management and prevention)” as core knowledge for the intensive care specialist. Or perhaps it applies to Section 2.6.2, "Professional Behaviour", which insists that "candidates should be able to ... demonstrate an understanding of the responsibilities of belonging to a profession, ...behave with compassion, integrity and honesty .... [and] demonstrate professional behaviour". 

Yes, CICM, they should be able to do that. But just like the random crossection of humans you would meet when you step on a bus, your coworkers in the ICU will come with a range of characteristics, not all of which will be uniformly adorable. You won't be able to change those fixed personality traits, but you can certainly use institutional and administrative resources to modify their behaviour and make it slightly less disgusting. This chapter focuses on this bad behaviour, where "bad" is defined as "that which may result in the loss of training accreditation" - bullying, workplace harassment, disharmony among staff, and all the other features which can colloquially be grouped under the heading "toxic workplace culture". The focus, as ever in Deranged Physiology, is on the prevailing local conditions such as are of interest to the end-stage CICM trainee preparing for their last exam, and are therefore highly Australocentric. Still, even though every unhappy family is unhappy in its own way, it is hoped that the discussion will have generalised applicability.  

Definitions

The CICM IC-20 contains all the possible definitions you could possibly want, including:

  • Discrimination: "treating a person with an identified attribute or personal characteristic (as set out in legislation) less favourably than a person who does not have the attribute or
    personal characteristic"
  • Harassment is "any type of unwanted behaviour that offends, humiliates or intimidates a person"
  • Sexual harassment is "unwelcome sexual behaviour that could be expected to result in a person feeling offended, humiliated or intimidated"
  • Victimisation is when "a person is treated unfairly due to that person having made a complaint of harassment"
  • Bullying behaviour is "behaviour that a reasonable person, having regard to all the circumstances, would expect could victimise, humiliate, undermine or threaten the person to whom the behaviour is directed"

These definitions, in case one raises an eyebrow at the language, appear to be standard across many organisations,  and is derived from the wording of Section 55A (1) of the Occupational Health, Safety and Welfare Act (1986), a document which seems to have been specific to the state of South Australia until it had been superseded in 2012. All jurisdictions generally have an Act like that, and they are all worded fairly similarly. In case anybody wants to sink into the swamp of occupational safety regulations, this article by Squelch & Guthrie (2010) is illuminating.

The college document includes all sorts of distressing examples to illustrate these behaviours, which are hopefully completely theoretical. This sort of stuff is not a uniquely vertical process, i.e. it would be unexpected if all the unpleasantness was purely a case of senior staff members being nasty to the junior staff members. Horizontal mistreatment (within a group of similar peers) does happen, and is perhaps more difficult to manage.

Bullying and harassment in the Australian medical community

When CICM performed a survey of their trainees and fellows in 2016, the findings were published by Venkatesh et al (2016), and were as follows:

  • Bullying: 32%
  • Discrimination: 12%
  • Sexual harassment: 3%

But, one might say, surely everybody does it. How do we as a specialist college compare to peer groups? Unfortunately, there is abundant data. For example, we have a directly comparable study from The Royal Australasian College of Surgeons (Crebbin et al, 2015), which reported the following rates:

  • Bullying: 39%
  • Discrimination: 18%
  • Sexual harassment: 7%

They also have breakdown of the data from subspecialist training programs, where the rates of reported bullying ranged from 49% for cardiothoracic surgery to a mere 22% for ophthalmology. More broadly, the AHPRA workforce surveys (2019 and 2020) revealed that it's worse at the bottom. They rolled all the nasty behaviours into one metric, and found that bullying harassment and discrimination were witnessed and experienced by 34% of overall doctors in training, but 47% of interns. 

Why did all the Royal and non-royal colleges suddenly decide that this was an issue they needed to tackle? Reader, it was not a spontaneous act of deliberate self-improvement. As with anything in medicine, large-scale positive change only takes place when somebody either dies or goes to the media. In this case, it was a public statement by a senior female surgeon in early 2015, instructing female surgical trainees to just comply with inappropriate requests for blowjobs, because to do otherwise would be career suicide. One needs to find some small comfort in the fact that a furore erupted over this statement, because its quiet recession into nothingness would have been something much much worse. Ridiculously, at the time professional bodies were still trying to pretend this was not a problem. The chair of the Women in Surgery committee at the Royal Australasian College of Surgeons at the time had blustered that "we have robust processes" and that, even though she herself had experienced sexual harassment, "it was not particularly serious". Those "robust processes", by the way, were turning up only one complaint per year, at a time where almost a third of their female trainees were reporting sexual harassment via anonymous surveys. In short, we, as a group of professionals, are just fundamentally terrible people. 

Responding to a complaint

Question 20 from the second paper of 2021 asked the exam candidates to manage a situation where, in a mentor-mentee meeting, a trainee confides in them that they have experienced bullying, and asks them not to tell anyone. Statistically speaking, if you work in a "Level 3" ICU, at some stage or another this will inevitably happen to you.  It will not necessarily be a trainee - this could be one of your colleagues, a friend, a peer. What do you do in such a situation?

It would be tempting to quote whole sections of the CICM IC-20 policy document here, specifically section 3.3.3, "Conducting an Interview with the Complainant". This describes the steps for responding to a formal written complaint, and resembles a procedural cop drama, including interviews with witnesses. Another useful document is this guide from Safe Work Australia

Initial response to the complainant

  • First, thank them for their openness. To bring up a matter like this requires some substantial courage and is often painful. 
  • Reassure them of confidentiality. 
  • Assure them that it will be taken seriously.
  • Ask them to describe the situation to you.
  • Ask them what they would want to happen, ideally (for example, an apology). 
  • Explain that, though the process can remain confidential and their complain can remain anonymous, their complaint is serious and needs to be escalated, as they have a right to workplace conditions that do not pose a risk to their mental health.

Establish, from the available information:

  • Is the behaviour bullying, discrimination, harassment? A relationship between trainee and supervisor is never without feedback, and some of this feedback can be very critical. 
  • How severe is the behaviour? Does the situation warrant an immediate step to minimise harm? This may take the shape of sending the staff member home, and organising a reliever.
  • What further information is required to have a better understanding of the situation? For example, it may be valuable to discuss the reported events with other staff who might have observed them. It would also be important to determine who would be the best person to gather that information.
  • Is this something that can be resolved at the level of the medical team, or does it need to be escalated?
  • Is this serious enough that an investigation is required? An investigation may be required if:
    • The complaint describes events occurring over a long period of time
    • Multiple coworkers are involved
    • The alleged behaviours are in dispute
    • Senior managers are involved in the bullying
    • It is ongoing, and previous efforts to resolve it have failed.

General principles of responding to such a complaint

  • Timeliness: prompt action
  • Neutrality and impartiality: all sides should be respectfully listened to
  • Documentation: keep records of all discussions and reports

Advantages of escalating a complaint

  • The complaint may result in a positive change.
  • Others who may be victimised by the same person may notice a difference in their treatment
  • The institution as a whole benefits from a culture of accountability, where calling out bad behaviour is an acceptable and expected norm
  • It may be psychologically beneficial for the trainee, as it is a positive step
  • It prevents the normalisation of a toxic workplace culture

Disadvantages of escalating a complaint

  • The complaint may not result in the desired change. Escalating a complaint to a person or body who are not in a position to make positive changes could not be expected to yield the desired result.
  • Statistically, most such complaints lead to an unsatisfactory end.  Llewellyn et al (2018) reported that, of those junior doctors who took action against bullying, "most reported ineffective or personally harmful outcomes".
  • The complaint may have definite negative consequences for the complainant and their supporters.  These negative consequences may be difficult to quantify and prove, but are clearly seen, as in the experiences of female surgical trainees.
  • Loss of trust: if the complainant insists that the discussion remains private, and the complaint is still escalated, they may feel betrayed and will not engage with the process in the future. If the trainee feels that the process is getting out of their control and is having unintended consequences for them, they may not raise this issue in the future.
  • The complaint may result in more bullying, particularly if the perpetrator develops the impression of invulnerability or impunity (eg. as the result of an impotent complaints process). 

Defined escalation pathways

The trainee in Question 20 from the second paper of 2021 is rightly concerned that making a formal complaint might "make their situation worse and could affect future job prospects". Historically, at least within the surgical specialist training program, that appears to have been the case. Therefore, there needs to be a confidential and potentially completely anonymous mechanism for vulnerable individuals to have access to a higher authority that could listen to their concerns and hopefully even act on them. In practice, sadly, the process of escalating concerns about nonclinical performance is usually a matter of finding the next larger bully. This is not uniformly a bad thing, and can take several shapes.

Escalation to the medical team leader. That would usually be the ICU consultant, the most senior medical staff member and the coordinator of the ICU team, who is expected to model good behaviour and maintain order. Unpleasant team dynamics and challenging interactions at the level of junior doctors could be dealt with at the level of the ward round.  The leadership qualities and conflict resolution skills of this consultant would therefore be the major limiting factors of this escalation pathway. Also, there is a nonzero chance that the consultant is the most toxic member of the ICU team. In which case...

Escalation to head of department. That's the person with the unenviable job of keeping order in a coven of highly intelligent narcissists.  Fortunately, if you got to be the head of department, it was hopefully because they have the necessary skills to manage challenging individuals. Unless, of course, the head of department is the problemQuestion 20 from the second paper of 2021 puts you in a position where the offender is actually the Director of the ICU. What the hell do you do with that? 

Escalation to an independent complaints department. Most large institutions tend to have a senior bureaucrat in a position  designed to absorb and redirect complaints from staff, including those directly related to behaviour. This person or department may be the next step of recourse. They may be a specific complaint-handling service, a human resources management office, or something specific to staff welfare. They are also usually independent, in the sense that they typically sit outside of the medical hierarchy,  and they may not have any clinician background. 

Escalation to peak training body. In Australia, that's CICM, who in the late 2010s suddenly found they have much to say about bullying and toxic workplace culture.  Perhaps to standardise the criteria for the diagnosis of bullying, and to signal that they embrace progressive virtues, they published IC-20 in 2016, and established the Welfare Special Interest Group. Concerns about major threats to trainee safety can be escalated directly to the college, and their main mechanism for managing these situations is to withdraw the accreditation for training from psychologically toxic units, an instrument that is designed to discourage registered trainees from working there. This has happened several times historically, though the standards for this are applied variably. For example, in 2019, the college withdrew accreditation from a notorious unit for bullying-related reasons, even though it passed every previous accreditation for at least two decades, during which period its trainees suffered some of the worst abuses. 

This instrument is a powerful AoE attack, but difficult to aim and unpredictable. For example, it may have little effect. Though embarrassing, the loss of training accreditation does not prevent an ICU from functioning, as there are seemingly limitless numbers of junior doctors who will still apply to work there. To be fair, these will not be any sort of elite veteran commandos of the critical care community (those would be siphoned off into nicer ICUs who retain their training accreditation), but you will be able to run the ICU with these people, probably without much interruption in clinical work. Alternatively, it may have massive and far-reaching effects, where an ICU has to close beds or change to an open model, decreasing the hospital capacity for complex surgery and emergency presentations, which then has implications for surgical waiting lists. Not to mention other training programs - imagine how the heads of neurosurgery, trauma, haematology and cardiothoracic surgery would react if their hospital suddenly loses the ability to look after their sickest patients, and their trainees no longer have access to the experience. In short, the effects could be trivial or catastrophic, and it is hard to determine prospectively which way the poison cloud will drift. The only predictable effect of the loss of accreditation is usually a spotlight, an injection of attention and funding, and regime change (the director usually resigns). Survivors can dust themselves off, establish a new leadership, and rebuild something better in the smoking crater.

Toxic workplace culture

The trainee's complaint of bullying to their mentor is usually a late symptom. One could consider it the tip of a horrible iceberg, only the last and most intolerable thing that happened, amid a background of some sort of constant low-grade disrespect. Moreover, it does not require a great stretch of the imagination to contemplate that the kind of person who humiliates and intimidates their junior subordinates will also not be especially pleasant to their colleagues. The same characteristics makes them an absolute delight at meetings and functions, to say nothing of their interactions with other departments in the hospital. Most often, this behaviour is not occurring in a vacuum - the entire team is responsible, as they either support and reinforce these behaviours, or simply look away and fail to call them out.  The question is, what do you do about this?

  • Lavage. If a cohort of entrenched staff are creating problems by acting through long-standing and mutually reinforced patterns of behaviour, one mechanism of managing this is to introduce a number of new staff to dilute their concentration. This has the effect of starting culture change by challenging the various toxic implicit assumptions that might be held by the old staff (assuming the new staff do not share those views). Various bystanders being routinely harmed by the bad behaviour will also have respite from it, as they will have the opportunity to work with some of the new staff.
  • Drainage. Retained resentment needs to be released so it can safely dissipate. Sometimes the reason for workplace animosity is some sort of unspoken anger or long-standing grudge which has never been discussed in the open. Perhaps somebody blocked somebody's grant, or never gave them credit on a paper, or muscled in on their coveted project, undermined them at the ward round, et cetera. Occasionally, bullied trainees grow up to become consultants in the same department, and the bullies find themselves in the company of resentful peers whom they had previously terrorised. The worst thing one could do here is to pretend that nothing happened. It needs to be discussed, potentially even using some sort of formal process with an independent mediator. There is a good chance that a mediated conflict resolution, or even just a conversation about the problem, will lead to some sort of closure. 
  • Adhesiolysis. A lack of understanding between individuals, or the absence of mutually agreed goals, can lead a workplace to fracture into exclusionist factions or cliques. Intelligent management of this problem involves mixing the staff in a way that changes this pattern and brings staff face-to-face with colleagues whom they would not normally interact with. This may mean creating a subcommittee to champion some aspect of quality assurance,  establishing a task force to respond to a root cause analysis, or sending a delegation to work with another department, as some examples. Giving these intentionally created groups some common goal to achieve can have the effect of bringing alienated staff into the social commonwealth of the department. This is functionally the same as all those horrible team-building exercises, except without the soulcrushing pointlessness.  
  • Reduction. Because narcissists tend to seek hierarchies, you need to dismantle the hierarchies.  In ICU, it is impossible to even the playing field of the ward round because the senior ICU specialist will always be at the top of the executive pyramid, but it is possible to reduce their influence. For instance, if morning handover is being used as an opportunity to bully or humiliate the junior staff, one may develop a system where handover between junior trainees occurs before the consultant arrives into the unit, thus removing their platform. In their non-clinical responsibilities, one can decrease their opportunities to dominate others by decentralising the process of running the department as much as possible, and dismantling old power structures. This might mean that, instead of having everybody report to the clinical lead of the education portfolio, you might have to have autonomous individuals with autonomous responsibility over simulation, primary exam teaching, etc, all acting independently and reporting directly to the head of department. 
  • Amputation. Sometimes, bad actors exist, whose level of insight into their own behaviour is already adequate, and who behave badly anyway. It would be a mistake to think that, with just a little extra patience and education, they will suddenly realise what they are doing and turn things around.  They know what they are doing; they just happen to think they are hilarious. Fortunately, there is usually enough of a trail of written complaints, that the governance of the hospital can take steps, ranging from suspension and transfer to something more drastic, like terminating their contract on grounds of their having breached the code of conduct. These steps may also inadvertently have the desired effect- most often, these people have a robust self-preservation instinct, and could change their behaviour very dramatically if they feel genuinely threatened by the events.