Workplace injustices are linked to hostile work environments and reduced morale.* This environment can negatively affect patient care, professional relationships, physical health, mental health, and job satisfaction. All health care employers have a responsibility to ensure that patients, staff, colleagues, physicians, and trainees are treated with respect, civility, and tolerance.
Harassment, bullying, and discrimination are three distinct interpersonal behaviors that over time can compromise patient safety, jeopardize patient outcomes, and be damaging to the well-being of all members of the health care team.
In June 2019, the Board of Regents of the American College of Surgeons (ACS) approved a Statement on Harassment, Bullying, and Discrimination, which is posted online. The ACS Women in Surgery Committee (WiSC) helped to develop the statement, and its Personal Empowerment Subcommittee has taken on addressing these issues. Selected educational programming at the annual meetings has focused on issues related to work environment optimization and empowerment of individuals to thrive in their professional situations. Most recently, this group has created a toolkit to facilitate ongoing learning over time and over disparate geographies, which is now available.
How bullying, harassment, and discrimination manifest in surgery
Bullying can be defined as the use of negative and aggressive interpersonal behaviors to intimidate and dominate others; these acts often are persistent and repeated. Examples include humiliation, insults, threats, coercion, isolation, and overwork—sometimes involving repetitive or meaningless tasks. Bullying often arises in contexts in which there is an imbalance of power, and as such may be common in the surgical workplace.
Current discrimination and harassment laws rarely address bullying concerns, although it is four times more prevalent in the workplace than illegal discrimination. Bullying is actionable under federal law only when the basis for it is tied to a protected category, such as race or sex. However, specific workplace civility policies can address respect in the workplace and hold employees accountable for bullying behaviors.
Harassment includes, but is not limited to, offensive remarks and actions about gender, race, religion, sexual orientation, age, culture, or ethnicity that can be used to threaten or dominate others. Like bullying behaviors, persistent and repeated harassment can lead to a hostile and intimidating work environment.
Sexual harassment is a form of discrimination that includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, which may “explicitly or implicitly affect an individual’s employment, unreasonably interferes with an individual’s work performance, or creates an intimidating, hostile, or offensive work environment.† The harasser can be anyone in the workplace, including patients. The victim does not have to be the person to whom the harassment is directed toward; anyone who is affected by the conduct in question can be considered a victim. Harassment violates Title VII of the Civil Rights Act of 1964, the Age Discrimination in Employment Act of 1967, and the Americans with Disabilities Act of 1990. Conduct that creates an intimidating, hostile, or offensive work environment as interpreted by reasonable people would be considered unlawful.
Discrimination entails negatively charged, differential treatment based on one’s personal characteristics or attributes, including, but not limited to, gender, race, religion, sexual orientation, culture, ethnicity, disability, or age. Implicit bias may contribute to discrimination and, as such, the effects are more subtle than with harassment and bullying. The effects of discrimination may be impediments in employment, practice, and/or career advancement. Federal laws as enforced by the Equal Employment Opportunity Commission protect against workplace discrimination.
What’s in the toolkit?
The toolkit, now available for ACS members, includes a PowerPoint presentation that can be used for personal education as well as in educational venues at which members might be called upon to present. The WiSC recognizes that topics such bullying, harassment, and discrimination can be emotionally charged and difficult to discuss among colleagues and trainees. Carefully crafted mock scenarios have been included that may be used to facilitate small group discussion. Scripts and instructions for mediation are available.
Also available are resources and hyperlinks for easy access to other organizations and materials that can help ACS members manage these challenging situations. Many resources to protect our human capital also are available through the Equal Employment Opportunity Commission. The ACS strongly supports protection of all individuals in a surgical environment. Recognizing existing problems, as well as the potential for future dilemmas, will help everyone not only reduce instances of bullying, harassment, and discrimination, but also prevent occurrences from developing.
Sample training scenarios
The toolkit contains several sample training scenarios that can be used for didactic teaching via presentation or via small group interaction. Scripts serve as a starting point for interaction and teaching points are highlighted and supported by additional references for study.
Sample scenarios include the following:
“What’s in a Name?”
Discrimination can occur with either overly familiar or overly formal address unequally applied during meetings. To decrease subtle prejudice, refer to everyone by first name or last name, showing no favoritism or denigration through unequal distribution of honorifics.
Here’s Looking at You
Appearance can influence decision-making. To minimize bias, develop performance review criteria in advance and stick exclusively to those.
Like Likes Like
The halo effect is a type of cognitive bias in which perceptions of a single trait impact overall impressions of a person’s character. Avoid making assumptions about unknown entities based on shared characteristics with known entities.
Go Along to Get Along
To promote diversity and inclusion, avoid conducting business in social settings that disadvantage certain employees who may represent minority groups.
Never Safe
You are never too experienced to be bullied. It can happen any time, any place, to anyone. Everyone is susceptible to bullying, though protected groups are more at risk.
Outward Ripples
Bullying has far-reaching impacts.
It’s Never Too Small a Gift
Microcultures can be positive as well as negative. Counterattack microaggressions with micro-positivity.
Implicit Means Implicit
Implicit bias, attitudes that subconsciously have an impact on our decisions, is inherently implicit, and is not recognized by the perpetrator, requiring formal training for awareness.
Jack and Jill Went Up a Hill, and Came Down with Different Amounts of Water
The Equal Pay Act of 1963 protects equal pay for substantially similar jobs, regardless of title or protected class. Conversely, it allows differential pay for the same job title if the job description is different.
You Can’t Fire Me, I Quit
Employment laws protect whistleblowers, dress code exceptions for religious beliefs, and protected classes from termination for unsupported perceptions. Medical leave beyond policy without documentation may lead to appropriate termination.
Additional resources, such as podcasts, will take on challenging topics in these realms.
