Bullying and Undermining – Changing Culture

Welcome to FY1. In your first few months, you will find your learning curve is steep and you may feel out of your depth and lost. This is normal-you will develop skills in your first few days, weeks and months that will make you unrecognisable from graduation day. One thing that you must not learn, however, is that people being rude or unkind to you is ok. The culture in the NHS is being eroded by pressures on funding, beds and short rotas. We are all working harder than ever before in less structured teams, often with unknown team members. We are probably leaving shifts after traumatic events with little opportunity to debrief or analyse how we feel. We might not see our team members/supervisors for weeks at a time. It can feel that there is no friendly face to speak to if things go wrong.

Doctors and healthcare staff at all levels are stressed and suicide rates are at record highs. Bullying is endemic-the RCOG has demonstrated that 60% of their members are recipients of bullying and undermining. I spend a lot of time with senior medical students and Foundation Year trainees and hear fantastic stories of brilliant care but also hear that F1’s are frequently the victims of bullying and undermining.

Being an F1 is about being shouted at. Since I started as an F1, I’ve been shouted at every day

People who bully have often been victims of bullying themselves. Bullying spreads through all layers of departments in a ripple effect. Bullies may not have insight into their behaviour. Finding ways to show that you have been affected by their behaviour may help them to change. We all have bad days and may express ourselves in ways at the height of a stressful situation that affects others but, by effectively communicating in a team, we can improve our care of patients.

Support in F1:

Many F1’s start without a clear idea of the support networks available to them in the hospital. All FY trainees will have to have a clinical supervisor-usually a consultant that will be working in your department who you should have clinical contact with so that they can assess and support you in work, an educational supervisor-who may or may not work with you for part of the year but will amalgamate clinical feedback, offer pastoral support and help to guide you in learning and development and a Foundation Training Programme Director who is your overarching supervisor. Both your CS and ES may have up to 4 trainees like you but your FTPD will be responsible for 20 or more foundation trainees. Whilst this means that contact is generally less, if you are experiencing issues with your clinical role, evidence of training in Horus eportfolio, personal life or health that affects work, the FTPD will be there to offer support. If there are problems in your working relationships with your immediate supervisors that can’t be resolved locally or you feel you would rather not discuss, the FTPD can help. Bullying and Undermining can be raised with any member of this team.

In addition to your immediate team, there is also the Guardian of Safeworking (GOS). People who are being undermined or bullied can often be inclined to try to stay at work for longer hours to improve their work to try to reduce negative comments. Exception reporting is a good way for your Foundation team to look at your department situation. Whilst being undermined and bullied can make you feel isolated that it is ‘just you’ it is extremely likely that there have been patterns of similar behaviour for a considerable time before you. If you are ever told not to exception report you MUST speak to the GOS/FTPD. This is taken very seriously.

The Director of Medical Education is another source of support and will often have oversight of all levels of trainees and doctors across the Trust. It is unusual for trainees to approach them directly but not unheard of. Usually, information will be fed through to them from the TPD’s of each level.

If you feel that no one is listening to your concerns, you can elicit help from the Deanery. Heads of Foundation school often know much more about placements than you could imagine. They will scrutinise GMC surveys and liaise with local teams to improve placements or withdraw them if there is no improvement.

If you feel that your health is beginning to suffer the Occupational Health Department should be contacted and you should be able to self-refer for advice. If you feel that you would rather not see someone in the Trust, you can either see your GP or self-refer to the Physicians Health Programme (which was just for doctors based in London but has recently won a national contract). The BMA runs a confidential helpline and counselling service and many deaneries now also have similar.

Is it important to eradicate cultural issues?

Bullying and undermining affects staff in their ability to offer good patient care. The Civility Saves Lives team have compiled evidence of its effects on staff and patients:

  • The Recipient-average 61% reduction in cognitive ability
  • The Bystander- average 20% reduction in cognitive ability and 50% less likely to help others
  • Patients and Relatives-75% reduction in net promoters of your organisation
  • The Team-overall reduction in cognitive ability and creativity in teams. On average, worse outcomes in all clinically significant measures

See: www.civilitysaveslives.com

Even checking in on a colleague who you are seeing bullied might empower them to report an incident which will ultimately improve their welfare and that of your patients. Recipients often feel that behaviour is precipitated by something that they have done wrong-doctors are horribly self-critical-and a colleague recognising that behaviour was unacceptable can go a long way to improving their self-worth.  A cup of coffee and a listening ear can really help and many team members will remember small acts of kindness for many years to come. It also encourages other team members to do the same for you.

Bullying and undermining can not only affect mental health but stress can also lead to a suppressed immune system and the common ‘holiday viruses’. It’s really important to look after yourself in work and outside and find an effective downtime activity. Many doctors will use mindfulness to regroup. This has been clearly demonstrated to reduce stress and anxiety.

In a similar vein, the ‘Circle of care’ from the GSTT simulation team is used to enable discussion about human values in healthcare. We all benefit from positive interactions within teams and from our patients. And feeling more positive about our role enables us to deliver better, more compassionate care to patients.

Schwartz rounds:

Changing culture across a department or Trust (or the NHS) can seem to be an impossible task.  Whilst it is true that one lone voice is unable to achieve change, in poor cultures, this one lone voice can attract a crowd that can really help. However, there is another way – Schwartz rounds. Schwartz Rounds were established by a Medical lawyer-Ken Schwartz-who, whilst receiving care in a hospice for terminal cancer, reflected that the most important aspect of his care as a patient was care and compassion from staff. He noted that staff were going from one very challenging situation to another and felt that they needed support and an area to discuss difficult situations.

See: Schwartz rounds

The Schwartz round is a safe area where a panel of 3-4 staff discuss emotionally challenging situations/themes in front of an audience who then contribute their reflections. They are facilitated by a clinician and another member of staff who are both trained to enable fruitful discussion without it becoming a problem-solving arena. Schwartz can, however, highlight situations to other members of staff who can then enable change. The Trust that I work in has looked at working patterns as a result of Schwartz and improved working conditions for staff with meetings outside Schwartz. Many trusts across the UK have them and attendees have been clearly demonstrated to show 50% lower levels of work-related stress and anxiety. It’s difficult to show clear research evidence of improved care to patients, however, due to numbers, but it’s logical to assume that happier staff improves patient care. Try to attend a Schwartz round in your Trust and consider contacting the Team. I’m a Schwartz medical lead and I love hearing ideas for rounds from all members of staff.


Bullying and undermining affect cognitive function in staff and can lead to health issues. We can all help to improve the culture at work and the FY doctors input is invaluable. Your ‘fresh eyes’ can see things that permanent members of staff cannot and elicit change for both staff and patient care.

Written by Leila CG Frodsham (Consultant Gynaecologist, Lead for Psychosexual Service, Foundation Training Programme Director, Schwartz Round Medical co-Lead, Guy’s and St Thomas’ NHS Trust & Module Lead for Transition to F1, Stage 3 MBBS, King’s College London

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