Advances in Anthropology
2013. Vol.3, No.4, 179-182
Published Online November 2013 in SciRes (
Open Access 179
Bullying and Aggressive Behavior among Health Care Providers:
Literature Review
Sergey Pisklakov*, Vasanti Tilak, Anuradha Patel, Ming Xiong
Department of Anesthe s i o l o gy and Perioperative Medicine, New Jersey Medical School,
University of Medicine and Dentistry of New Jersey, Newark, USA
Email: *
Received June 23rd, 2013; revised Ju ly 26th, 2013; accepted August 2 4 th, 2013
Copyright © 2013 Sergey Pisklakov et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Bullying is defined by American Psychological Association as an aggressive behavior which is intended
to cause distress or harm and that involves an imbalance of power or strength between the aggressor and
the victim. Bullying in the workplace is angering enough people these days to be fueling a nationwide
grass-roots legislative effort to force companies to draft and enforce policies aimed at stopping it. Requir-
ing such policies, according to those pushing the legislation, is not an attempt to spawn lawsuits, but an
effort to force organizations to deal with the problem. Bullying is blamed for unnecessarily creating high
costs of turnover, insurance claims and thwarted productivity. Disruptive behavior has been observed in
almost all members of the healthcare team from physicians and nurses to pharmacy, radiology, and labo-
ratory staff members. Physician behavior, however, may have the greatest impact because of the position
of authority that doctors hold as members of the healthcare team. A team member may, from fear of in-
timidation or patronization, withhold valuable or even critical input, such as a medication error or a
breakdown in adherence to safety protocols. Hospitals, departments and individual personnel need to de-
velop a higher level of awareness of the problem both in others and in them. Anti-bullying policies should
be given a higher profile.
Keywords: Aggressive Behavior; Bullying; Impact of Bullying on Healthcare Productivity and Patient
Safety; Antibullying Policies
This Bullying is defined by American Psychological Asso-
ciation as an aggressive behavior which is intended to cause
distress or harm and that involves an imbalance of power or
strength between the aggressor and the victim. A more objec-
tive—if somewhat wordy—definition used by Swedish workers
is that bullying emerges when one or several persons over a
period of time persistently perceive themselves to be on the
receiving end of negative actions from one or several persons in
a situation where the one at the receiving end has difficulty in
defending him or herself against these actions. This definition
incorporates the subjective feelings of the person on the receiv-
ing end, even where an individual may have behaved aggres-
sively but with no intention to harm. It puts an onus on each in-
dividual to be mindful of the effect of their actions on others. It
does not offer protection to those falsely accused of bullying.
The main features of this definition are negative behaviors, per-
sistence over time and an imbalance of power (Einharsen et al.,
1994). Bullying can be physical, relational, peer sexual harass-
ment and stereotyping. It is a way to gain power (Kozlowska et
al., 1997).
Bullying in the workplace is angering people these days. It is
fueling a nationwide grass-roots legislative effort to force com-
panies to draft and enforce policies aimed at stopping it. Re-
quiring such policies is not an attempt to spawn lawsuits. It is
an effort to force organizations to deal with the problem. Bully-
ing is blamed for unnecessarily creating high costs of turnover,
insurance claims and thwarted productivity (Rosenstein &
O’Daniel, 2005).
Necessity to Create Antibullying Policies
In January 2009, a new standard issued by the Joint Commis-
sion [formerly JCAHO] went into effect. It requires hospitals to
have “a code of conduct that defines acceptable, disruptive, and
inappropriate staff behaviors” and for its “leaders [to] create
and implement a process for managing disruptive and inappro-
priate staff behaviors.” The rationale for the standard states:
“Leaders must address disruptive behavior of individuals work-
ing at all levels of the [organization], including management, cli-
nical and administrative staff, licensed independent practitio-
ners, and governing body members.” A Joint Commission sen-
tinel alert includes “uncooperative attitudes” and “condescend-
ing language or voice intonation and impatience with questions”
as disruptive behaviors. The Joint Commission’s first-ever alert
about the problem is the latest industry effort to address an
issue that has challenged the medical community for years (The
Joint Commission, 2009). Suggested actions include systems to
detect and deter unprofessional behavior; more civil responses
to patients and families who witness bad acts; and overall train-
*Corresponding author.
ing in “basic business etiquette,” including phone skills and
people skills for all employees (Joint Co mmissi on -Senti nel Event
Alert, 2008). Administrative response to bullying has been so
far ineffective. In some cases no action was taken. This lack of
action could lead to serious liabilities since these incidents are
not only about bullying, but also sexual harassment and discri-
Disruptive behavior has been observed in almost all members
of the healthcare team-from physicians and nurses to pharmacy,
radiology, and laboratory staff members. Physician behavior,
however, may have the biggest impact because of the position
of power that doctors hold as members of the healthcare team
(Quine, 2002). A team member may, from fear of intimidation
or patronization, withhold valuable or even critical input, such
as a medication error or a breakdown in adherence to safety
protocols (Rosenstein, 2005).
To ensure good patient care and respect among all healthcare
professionals is at the very foundation of the ethics advocated
by the American Medical Association. Intimidating, condescen-
ding, off-putting, or discouraging behavior by the physician in-
hibits positive team work. If OR staff works sub optimally be-
cause of disruptive behavior by the physician or another team
member, overall care quality is compromised and patient safety
is threatened. To mitigate these risks, healthcare organizations
must re-examine their hospital harassment policies to ensure
those policies include specific prohibitions against gender dis-
crimination and harassment. Hospitals also need to create a
workplace conduct policy forbidding bullying or harassment re-
gardless of gender. Once policies are in place, comprehensive
training courses should be given to all supervisors and physi-
cians. When policies violated, action should be taken.
Bullying as a Form of Aggression
Bullying is a form of aggression. Physical bullying is obvi-
ous in our society. It tends to be the province of children.
Adults are more subtle and devious in their approach, and their
bullying can take a variety of forms, many of which may not be
obvious to a third party. This allows bullies to continue their
activities unchecked and enables them to do what they wish
(Paice, 2004). The outburst in the OR by a surgeon or anesthe-
siologist is not uncommon. Misconduct against nurses is com-
mon (Uhari, 1994).
Bullying and mistreatment during training is also a part of
the experience of many doctors, medical students or residents
(Quine, 2002). Psychological abuse, gender discrimination, and
sexual harassment were prevalent in one study (Stratton, 2005).
Nursing staff have been implicated in intimidating and harass-
ing residents by verbal comments (Farrell, 1999; Coverdale,
2005); senior residents have also been implicated (Cohen, 2008;
Cook, 1996; Daugherty, 1998). Of course, sometime excessive
mentorship can be misinterpreted by trainee as bullying. An in-
dividual’s personal beliefs and lack of self confidence colors
their interpretation of any communication; criticism may be in-
ferred where none was implied. Curt behavior by senior doctors
may be interpreted as criticism by juniors even when this was
not intended. Where the recipient of certain critical or aggres-
sive behaviors is more junior and therefore constrained in their
perceived ability to respond to it, this can be a problem (Mosca-
rello, 1994).
A bully tends to be in a position of relative power. This al-
lows him or her to behave towards one or many others in an
unacceptable way. This can be as simple as making it impossi-
ble for subordinates to progress ups the career ladder by ensur-
ing that they are not given opportunities (Cohen, 2008). Bullies
may prevent a subordinate from developing their ideas, and
develop them as if they were their own. They may manipulate
subordinates to take on unacceptable commitments by playing
on their vulnerabilities. The bullies may be perceived as good
managers because they get more work done. In the medical
world, bullies may avoid taking their fair share of unpleasant
tasks in a department. They may do this by offloading some of
these tasks onto others who are powerless to protest. If the af-
fected individual does complain, the bully may threaten to ac-
tivate certain sanctions within their power, to which the victim
is vulnerable (Daugherty, 1998). The situation is like that of
blackmail. It is not that the victim cannot complain; it is that
they perceive themselves as helpless (Cook, 1996; Kozlowska,
Often bullying is an extension of forms of negative behavior
frequently seen in the medical world (Carr, 1997). When and
where does it cross the line? Is there then an acceptable level of
bullying? Awareness of bullying as a problem has increased,
and there is evidence that the prevalence is high in medicine.
Nevertheless, there is also the possibility that the behavior ex-
perienced by some as bullying is perceived by others as normal
(Ahmer, 2009; Quinne, 1999, 2002).
Who Are the Bullies?
People who are accused of bullying fall into two groups. The
first group is those who intend to hurt and humiliate their vic-
tim, and who choose their victim with a view to getting pleas-
ure from their power over them. This is uncommon. The second
group is made up of people who perceive their behavior as rea-
sonable, while the victim perceives it as bullying. When indivi-
duals in this latter group are accused of bullying they are often
mortified and suffer a major blow to their self-esteem. Problem
situations for this second group often relate to a senior/junior
interaction. There are several reasons for this. In the past, senior
role models may well have shown bullying behaviors. Many se-
nior doctors are focused, dedicated and, at times, obsessional
individuals who do not suffer fools gladly. They are often very
self-critical. They expect equal levels of self-criticism, dedica-
tion and focus from their junior staff. Where the levels of activ-
ity they require from trainees are outside the normal range they
are likely to be accused of bullying (Paice, 2004; Daugherty,
Another category of bully is the medical manager. Frequent-
ly, they have been given little training for the task in hand and
the demands of the system are often unrealistic. A proportion of
these doctors, under pressure, may resort to any method by
which they can achieve results, even if this amount to bullying
(Houghton, 2003).
Bullying is still part of the organizational culture. For exam-
ple, even though junior doctors' hours have been agreed, there
is, in some specialties, pressure to arrive early and leave late, ir-
respective of the amount of work to be done. Lastly, even nor-
mally amiable senior doctors may behave badly when under
personal or professional stress (Johnson, 2009; Roberts, 2009).
Causes of Bullying
One of the reasons is the lack of training for doctors and
sometimes other managers in management or leadership skills.
Open Access
They simply may not appreciate that people are different (Dau-
gherty, 1998).
Absence self-criticism may exacerbate bullies’ reaction to
the confrontational situation. Very self-critical people become
depressed, while individuals with low levels of self-criticism
have problems in relationships with patients and colleagues
(Paice, 2004; Daugherty, 1998).
Why Victims Do Not Speak Out against Bullies?
Victims of bullying often believe that a complaint would ne-
gatively affect their professional progress, and with an inten-
tional bully this might be the case. Thus, incentives to complain
are outweighed by the perceived incentives to keep quiet (Mar-
gittai, 1996). This creates a “survival” culture, not too far re-
moved from that of prison or the armed forces.
The consequences of bullying are devastating. Bullying is
responsible for victims becoming stressed, depressed and in-
tending to leave their jobs. The 2004 study reported that 37% of
doctors in training had been bullied in the past year (Uhari,
Although there would appear to be a difference between in-
tentional and unintentional bullying, the initially unintentional
violator may gain satisfaction or results from this form of be-
havior, which will then be reinforced. Intentional bullying is a
dysfunctional form of behavior which needs intervention and
help (Cohen, 2008). Approache s to unintentional bully ing should
be both educational and organizational. Work with the individ-
ual accused of bullying may need to include psychotherapy to
explore the reasons for bullying or aggressive beh avior. It should
also include work on interpersonal and self-awareness skills so
that the bully can explore and adopt alternative ways of behav-
ing (Houghton, 2005). This approach, while emphasizing that
bullying is unacceptable, also recognizes that bullying behavior
may be understandable and that those using it need help to
change (Einharsen, 1994). The organizational culture also needs
to change. Many companies have put in place clearly defined
written policies to prevent bullying and harassment at work, but
the problem persists. Management pressures, which essentially
amount to bullying, may compel senior doctors to take on im-
possible clinical loads or to work in unacceptable facilities.
They may in turn adopt bullying behavior with subordinates in
response to these pressures. The problem may also persist be-
cause, although there is more general awareness of the problem,
many victims still do not speak out, for a variety of reasons.
One appalling truth is that some of these individuals have such
low self-esteem that they do not recognize their treatment as
bullying (Kozlowska, 1997; Johnson, 2009).
Hospitals, departments and individual personnel need to de-
velop a higher level of awareness of the problem both in others
and in them. Anti-bullying policies should be given a higher
profile. This should encourage victims to come forward so that
individual bullies can be identified. The unintentional bully will
usually, although not always, respond to the strategies outlined
above and modify their behavior. They may well respond to
personal approaches on the part of the victim. Direct approach
of the bully may be counterproductive. The victim should keep
a careful record of all behavior they perceive as bullying. It is
important to ascertain that what you dealing with are bullying.
Once confirmed that you are dealing with bullying, you should
approach the bully’s line manager or the human resources de-
partment. Finally, you could also approach your professional
association for advice and support (Houghton, 2004).
We know little about how verbal abuse or bullying is trigger-
ed and how it might be prevented (Farrell, 1999). Primary pre-
ventive methods include providing educational materials and
communication skills training for residents, staff, and educators
(Baldwin, 1991). Education on abuse, discrimination, and har-
assment in the workplace, and how these can be addressed and
averted, can also be presented in formal and informal curricula.
Such initiatives should promote culture of collegiality and re-
spect for all faculty, staff, and trainees (Quine, 1999). Seconda-
ry preventive measures rely on reporting mechanisms. Any oc-
casion of abusive or discriminatory language or behavior needs
to be addressed. Measures such as debriefing and supportive
counseling should aim to alleviate the psychologically distress-
ing consequences of these behaviors for all recipients and ob-
servers. Universal focus on professionalism in medical educa-
tion and professional behavior of physicians in practice should
help us to eradicate this unacceptable behavior (White, 2000).
Ahmer, S. et al. (2009). Bullying of trainee psychiatrists in Pakistan: A
cross-sectional questionnaire survey. Acad Psychiatry, 33, 335-339.
Baldwin, D. et al. (1991). Student perceptions of mistreatment and ha-
rassment during medical school: A survey of ten US schools. West-
ern Journal of Medicine, 155, 140-145.
Carr, M. et al. (1991). A survey of Canadian psychiatric residents regar-
ding resident-educator sexual contact. American Journal of Psychia-
try, 148, 216-220.
Carr, M. (1997). Comment. Australian & New Zealand Journal of Psy-
chiatry, 31, 653-654.
Cohen, J. et al. (2008). The happy docs study: A Canadian Association
of Interns and Residents well-being survey examining resident phy-
sician health and satisfaction within and outside of residency training
in Canada. BMC Research Notes, 1, 105.
Cook, D. et al. (1996). Residents’ experiences of abuse, discrimination,
and sexual harassment during residency training. Canadian Medical
Association Journal, 15 4, 1657-1665.
Coverdale, J. et al. (2001). A survey of threats and violent acts by pa-
tients against training physicians. Medical Education, 35, 154-159.
Coverdale, J. et al. (2005). Protecting the safety of medical students and
residents. Academic Psychiatry, 29, 329-331.
Daugherty, S. et al. (1998). Learning, satisfaction, and mistreatment du-
ring medical internship: A national survey of working conditions.
JAMA, 279, 1194-1199.
Einharsen, S. et al. (1994). Bullying and its relationship to work and
environment quality: An explorato ry study. European Journal of Work
and Organisationa l Psychology, 4, 381- 404.
Farrell, G. (1999). Aggression in clinical settings: Nurses’ views: A fol-
low-up study. Journal of Advanced Nursing, 29, 532-541.
Hoosen, I., & Callaghan, R. (2004). A survey of workplace bullying of
psychiatric trainees in the West Midlands. Psychiatric Bulletin, 28,
Houghton, A. (2003). Bullying in medicine. British Medical Journal,
326, 12.
Houghton, A. (2005). Tips on dealing with bullies. British Medical
Journal Career Focus, 33 0 , 201-202.
Huntoon, L. (2004). Abuse of the “disruptive physician” clause. Jour-
Open Access 181
Open Access
nal of the American Physicians and Surgeons, 9, 68.
Johnson, S. (2009). International perspective on workplace bullying
among nurses: A review. International Nursin g Review, 56, 34- 40.
Joint Commission (2008). Sentinel event alert—Behaviors that under-
mine a culture of safety.
The Joint Commission (2009). Accreditation requirements.
Kozlowska, K. (1997). Adverse experiences in psychiatric training, part
2. Australian & New Zealand Journal of Psychiatry, 31, 641-652.
Margittai, K. (1996). Forensic aspects of medical student abuse: A Ca-
nadian perspective. The Bulletin of the American Academy of Psy-
chiatry and the Law, 24, 377-385.
Moscarello, R. et al. (1994). Differences in abuse reported by female
and male Canadian medical students. Canadian Medical Association
Journal, 150, 357-363.
Paice, E. et al. (2004). Bullying among doctors in training: Cross sec-
tional questionnaire survey. British Medical Journal, 329, 658-659.
Quine, L. (2002). Workplace bullying in junior doctors: Questionnaire
survey. British Medical Journal, 324, 878-879.
Quine, L. (1999). Workplace bullying in NHS community trust: Staff
questionnaire survey. BMJ, 318, 228-232.
Roberts, S. et al. (2009). The effect of oppressed group behaviors on
the culture of the nursing workplace: A review of the evidence and
interventions for change. Journal of Nursing Management, 10, 1365-
Rosenstein, A., & O’Daniel, M. (2005). Disruptive behavior and clini-
cal outcomes: Perceptions of nurses and physicians. The American
Journal of Nursing, 105, 54-64.
Stratton, T. et al. (2005). Does students’ exposure to gender discrimina-
tion and sexual harassment in medical school affect specialty choice
and residency program selection? Academic Medicine, 80, 400-408.
Uhari, M. et al. (1994). Medical student abuse: An international pheno-
menon. JAMA, 271, 1049-1051.
Vanineveld, C. et al. (1998). Discrimination and abuse in internal me-
dicine residency. Journal of General Internal Medicine, 11, 401-405.
White, G. (2000). Sexual harassment during medical training: The per-
ceptions of medical students at a university medical school in Aus-
tralia. Medical Education, 34, 980-986.