2014 APDS SPRING MEETING
Workplace Bullying of General Surgery
Residents by Nurses
Lisa L. Schlitzkus, MD,*, Kelly N. Vogt, MD,*, Maura E. Sullivan, PhD,*
and Kimberly D. Schenarts, PhD
Department of Surgery, University of Southern California, Los Angeles, California; LACUSC Medical
*
Center, Los Angeles, California; and Department of Surgery, University of Nebraska Medical Center,
Omaha, Nebraska
OBJECTIVE: Workplace bullying is at the forefront of social
behavior research, garnering signicant media attention.
Most of the medical research has addressed bullying of
nurses by physicians and demonstrates that patient care and
outcomes may suffer. The intent of this study was to
determine if general surgery residents are bullied by nurses.
DESIGN: A survey instrument previously validated (Neg-
ative Acts QuestionnaireRevised) to evaluate for work-
place bullying was modied to reect the resident-nurse
relationship. After institutional review board approval, the
piloted online survey was sent to general surgery program
directors to forward to general surgery residents. Demo-
graphic data are presented as percentages, and for negative
acts, percentages of daily, weekly, and monthly frequencies
are combined.
SETTING: Allopathic general surgery residencies in the
United States.
PARTICIPANTS: General surgery residents.
RESULTS: The response rate was 22.1% (n 452). Most
respondents were men (55%) and had a mean age of 29
years (standard deviation 7). Although 27.0% of the
respondents were interns, the remaining classes were equally
represented (12%-18% of responses/class). The respondents
were primarily from medium-sized residency programs
(45%), in the Midwest (28%), training in university
programs (72%), and rotating primarily in a combined
private and county hospital that serves both insured and
indigent patients (59%).
The residents had experienced each of the 22 negative acts
(11.5%-82.5%). Work-related bullying occurs more than
person-related bullying and physical intimidation. Ignoring
Presented as podium presentation at the 2014 Meeting of the Association of
Program Directors in Surgery, Chicago, Illinois, April 2014.
Correspondence: Inquiries to Lisa L Schlitzkus, MD, LACUSC Medical Center,
2051 Marengo Street, IPT C5L100, Los Angeles, CA 90033; fax: (323) 441-9907;
e-mail: lisaschlitzkus@gmail.com
Journal of Surgical Education  & 2014 Association of Program Directors in Surgery. Published by
Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.08.003
of recommendations or orders by nurses occurs on a daily,
weekly, or monthly basis for 30.2% of residents (work-
related bullying). The most frequent person-related bullying
act is ignoring the resident when they approach or reacting
in a hostile manner (18.0%), followed by ignoring or
excluding the resident (17.1%).
CONCLUSIONS: Workplace bullying of general surgery
residents by nurses is prominent. Future research is needed
to determine the toll on the residents well-being and
patient outcomes. ( J Surg 71:e149-e154. J C 2014 Associa-
tion of Program Directors in Surgery. Published by Elsevier
Inc. All rights reserved.)
KEY WORDS: workplace bullying, general surgery resi-
dents, nurses
COMPETENCIES: Professionalism, Interpersonal and
Communication Skills, Patient Care
INTRODUCTION
Workplace bullying has recently garnered signicant atten-
tion,1 affecting various organizations from schools2 and
governmental agencies3 to the National Football League.4
Health care workers are at greater risk as described by Zapf
et al.5 because their jobs require a high level of personal
involvement, that is, a form of emotional labour and
[the] more possibilities for being attacked exist.
Current data are equivocal about the gender and organ-
izational status (superiors vs. subordinates) of the victims of
workplace bullying.6 However, most research about work-
place bullying has been conducted in European countries
with varying cultural, workplace, and legal differences.6
Thus, its applicability to the American health care system is
unknown. In 1967the same year President Lyndon
Johnson expanded the Afrmative Action Policy to cover
discrimination on the basis of genderStein rst described
the game of the doctor-nurse relationship where women
1931-7204/$30.00 e149
were nurses and men the physicians with clearly dened roles.7 Surveymonkey.com) to their residents. The survey was
Much of the bullying literature with regard to American health administered during the nal 2 weeks of October. All
care has been published in the nursing literature. Numerous survey answers were condential; no individual resident
nursing organizations lobby against workplace bullying of was contacted, and the program directors were used to
nurses by issuing position statements, calling for dialogue, ensure condentiality. Further, 2 generalized reminders
and petitioning for zero tolerance policies.8 were sent out to the program directors asking them to
With respect to physician trainees, the Association of remind their residents to complete the survey.
American Medical Colleges advocates for medical students Data collected included demographics and responses to
and annually assesses bullying on the Medical School the 22 survey questions. The size of the residency programs
Graduation Questionnaire.9 Unfortunately, data about the was categorized based on the number of residents per year
bullying of residents are not formally gathered, and the
TABLE 1. Demographics
topic is rarely addressed.10 Thus, we sought to describe the
workplace bullying of general surgery residents: a group of Resident gender
learners with increased responsibility in a discipline where Male 55.1%
bullying has previously been reported at higher levels.11,12 Female 40.7%
Resident clinical year
Specically, we questioned whether general surgery resi- PGY 1 27.0%
dents are bullied by nurses based on the unequal balance of PGY 2 18.8%
medical knowledge on the physicians part, and experience PGY 3 15.3%
and tenure of nurses who contribute to the residents PGY 4 13.5%
education. PGY 5 11.7%
Research year 9.5%
Resident race
White 69.5%
METHODS African American 3.5%
Hispanic 5.8%
This study was approved by the Biomedical Institutional Asian 11.9%
Review Board at the University of Southern California. Other 4.9%
Resident sexual orientation
Participation in the survey was voluntary and without Heterosexual 92.9%
compensation. The Negative Acts QuestionnaireRevised Homosexual 1.8%
is a previously validated instrument that is utilized by Bisexual 0.7%
various organizations to survey workplace bullying.13 Other 0.2%
It targets the persistent exposure to interpersonal aggression Played team sport (high school or college)
Yes 77.9%
and mistreatment from colleagues, superiors, or subordi- No 17.9%
nates.13 The Negative Acts QuestionnaireRevised was Resident in military
ideal for this study, given its brevity, reliability, adaptability Yes 4.9%
to many institutional settings, and development specically No 90.9%
for Anglo-American culture.13 The 22 questions were Nurse in residents immediate family
Yes 24.8%
tailored to reect the general surgery resident and nurse No 71.0%
relationship. Additionally, demographic questions were Surgeon in residents immediate family
included before the instrument questions. Yes 10.2%
No 85.6%
Type of program
Instrument Validity University 71.9%
Community 23.5%
The validity of the survey tool was conrmed by piloting Military 2.2%
with 15 obstetric/gynecological residents. We felt this was a Location of program
reasonable comparison, given the similarity of a surgical Northeast 4.6%
East 15.7%
background. Following completion of the pilot survey, Southeast 15.9%
1 investigator discussed the survey tool with the pilot South 11.3%
participants to ensure that the survey questions and answers Midwest 27.7%
were understandable. Southwest 5.1%
West 17.3%
Small (2-4 residents/y) 28.8%
Survey Methodology Medium (5-7 residents/y) 44.9%
Large (Z8 residents/y) 23.9%
A personal invitation e-mail was sent to all allopathic general Private hospital 21.2%
surgery program directors. They were asked to electronically County hospital 19.5%
distribute the link to the online survey (designed using Combined or hospitals of both type 35.6%

e150 Journal of Surgical Education  Volume 71/Number 6  November/December 2014

(Table 1). Age is presented as a mean with standard
deviation and the remaining data as frequencies with
associated percentages.
RESULTS
Presently, there are 249 general surgical residencies with
6662 residents; a total of 244 programs with 6550 residents
were contacted (e-mails from 5 programs were returned).
Survey responses were received from at least 1 resident in 76
programs. A total of 452 responses were received from the
2044 residents represented in these programs, giving a
response rate of 22.1%.
Most respondents were men (55.1%) and had a mean age
of 29 years (standard deviation 7). Although 27.0% of
the respondents were interns, the remaining classes were
equally represented. Respondents were primarily from
medium-sized residency programs (44.9%) in the Midwest
(27.7%). Most were training in university programs
(71.9%) and rotated primarily in a combined private and
county hospital that serves both insured and indigent
patients (59.3%). Demographic data are summarized in
Table 1.
The 22 questions describe negative acts and are divided
into work-related (Table 2), person-related (Table 3), and
physical intimidation (Table 4) acts of bullying.13,14 Exam-
ples of work-related bullying include giving someone too
many, too few, or too simple tasks or persistently criticizing
them or their work.15 Personal acts of bullying include
slander, social isolation, and insinuation about mental
health,15 whereas physical intimidation includes acts or
threats of violence.16 The overall response rates to each
question are included in Tables 2-4.
Work-related bullying occurs more than person-related
bullying or physical intimidation and on a more regular
basis (Tables 2-4). Interestingly, the most frequent negative
act by nursing staff is ignoring residents recommendations
or orders (Table 2). However, among person-related bully-
ing, the most frequent act was ignoring or excluding the
resident, followed closely by the nurse ignoring the resident
when they approach or reacting to the resident in a hostile
manner (Table 3). Physical intimidation is the type of
bullying most people recognize and give as an example
when asked, What is bullying? It is worrisome that
physical intimidation is still prevalent today and that
shouting and making residents the target of spontaneous
anger occurs with monthly, weekly, and even daily fre-
quency (Table 4).
DISCUSSION
Workplace bullying has many similar and euphemistic
terms: workplace violence, lateral violence, harassment,
mobbing, etc; some trivialize these behaviors: incivility,
disrespect, difcult people, personality conicts, disruptive
behavior, etc. All of these share the concept that the victim
must be repeatedly exposed to negative, aggressive behav-
ior at work. These behaviors are mainly of psychological
nature, resulting in the victim feeling humiliated, intimi-
dated, fearful, or constantly punished.17 Researchers who
have signicantly contributed to workplace bullying liter-
ature acknowledge that these acts alone commonly occur
in the workplace,17 but the repetition (frequency),
duration (over a period of time), and patterning (of a
variety of behaviors involved) are the hallmarks of work-
place bullying.18
Several of the acts such as monitoring work and even
ignoring orders can be attributed to nurses advocating for and
protecting their patients on the grounds that residents are still
in training. However, it is shocking, that acts such as
withholding information, pressure to not report errors, and
ignoring or excluding residentsacts that could directly affect
patient care and harm a patientstill occur in this day and
age. Additionally, several acts that residents reported should
never be tolerated in any workplace: shouting, threatening
violence, shovingthese are simply unacceptable.
The effect of workplace bullying on patient safety, from
medication errors to reporting changes in a patients
condition, led the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) to issue a Sentinel
Event Alert in 2008.19 JCAHO recognized that these
behaviors have been exhibited by nurses, pharmacists,

TABLE 2. Overall Responses for Work-Related Bullying

Never Now and Monthly Weekly Daily
Item Wording Has a Nurse Ever (%) Then (%) (%) (%) (%)
Withheld information which affected your performance 33.0 46.2 5.8 3.8 0.7
Asked you to do work below your level of competence such
31.9 31.9 8.8 12.2 4.6
as asking a chief to do intern level work
Ignored your recommendations or orders 17.5 41.8 14.8 10.8 4.6
Made a request of you with an unreasonable deadline 57.5 19.2 6.6 5.1 1.2
Excessively monitored your work 58.6 21.7 5.1 2.2 0.9
Pressured you not to report a near miss incident or critical
76.5 10.2 1.8 0 0
patient error
Deliberately contributed to an unmanageable workload 69.9 11.5 4.6 2.0 0.4

Journal of Surgical Education  Volume 71/Number 6  November/December 2014 e151

TABLE 3. Overall Responses for Person-related Bullying
Never Now and Monthly Weekly Daily
Item Wording Has a Nurse Ever (%) Then (%) (%) (%) (%)
Humiliated or ridiculed you in connection with your work 50.2 31.2 5.1 2.9 0.4
Made you or expected you to perform trivial or unpleasant tasks
in addition to your normal responsibilities such as scut work, 50.4 29.9 4.6 4.4 1.5
changing bedpans, etc.
Spread gossip and rumors about you 53.1 26.3 4.2 3.5 1.8
Ignored or excluded you 27.7 45.6 10.2 5.8 1.1
Insulted or made offensive remarks about you, your attitude,
59.7 22.6 4.4 2.0 0.2
or your private life
Made hints of signals that you should quit your job 86.9 2.0 0.4 0.4 0.2
Repeatedly reminded you of your errors or mistakes 64.8 21.0 3.3 0.9 0.4
Ignored you when you approached them or have you ever
29.4 42.3 10.4 4.9 2.7
faced a hostile reaction when you approached them
Persistently criticized you about your errors or mistakes 71.2 14.2 2.0 1.3 0.7
Made you the butt of a practical joke 82.7 5.5 0.9 0.2 0.2
Made allegations against you 69.0 16.8 1.8 0.9 0.2
Excessively teased you or been excessively sarcastic toward you 67.3 16.8 2.9 1.5 0

therapists and other support staff,19 but in revisiting the
topic 5 years later, the medical director of JCAHO stated it
is the behavior of the doctors which most often causes
problems.20 Interestingly, the rst reference of the JCAHO
Sentinel Event Alert and the revisiting commentary dem-
onstrate 68% and 65% of respondents, respectively, had
witnessed disruptive behavior by nurses.21,22 Specically,
48% of physicians had witnessed nurses exhibiting disrup-
tive behavior, and 28% of all respondents felt disruptive
behaviors by any staff occurred most often in general
surgery.22 Our ndings demonstrate that residents had
experienced each of the 22 negative acts at the hands of
nurses with frequencies ranging from 11.5% (physical
violence) to 82.5% (ignored recommendations or orders).
Excluding physical violence, each of the remaining 21
negative acts occurred on a daily to monthly basis for
1.3% to 30.2% of respondents.
Rosenstein and ODaniel22 further examined the clinical
effect of disruptive behaviors that may contribute to adverse
patient events: 83% of respondents felt that disruptive
behavior caused loss of concentration, 89% felt that it
reduced team collaboration, 87% felt that it reduced
information transfer, 91% felt that it reduced communica-
tion, and 99% felt that it impaired the nurse or physician.
Nearly 1 of 5 respondents were aware of specic adverse
events that occurred as a direct result of disruptive
behavior.22 Residents too can be distracted, have difculty
concentrating, not want to go to a bedside and write an
order, or ask the nurse a clinical question when facing a
negative, aggressive nurse. It is common for general surgery
residents to be highly involved in patient care, taking in-
house or home calls. They are often the rst responders,
answering questions, writing orders, making plans, and
intervening in patient care. If general surgery residents are
experiencing workplace bullying at the hands of nurses, then
avoiding interaction with those individuals would be a likely
and understandable reaction. What effect this discord has
on patient safety is unknown and may be an area for future
research.
The effects of workplace bullying on the victim have been
documented and include health issues (hypertension,
insomnia, and gastrointestinal problems) and mental health
issues (posttraumatic stress disorder, depression, and suicidal
ideation) extensively documented by Namie.23 The suicide
rate of male physicians is 40% higher than in the general
male population and that of female physicians is 130%
higher than in the general female population.24 Moreover,
physicians are more likely to be effective at such attempts.24
Residents also have a higher depression and suicide rate than
observed in the general population.25 Residents who were
sexually harassed at a Canadian hospital experienced
embarrassment (24.0%), anger (23.4%), frustration

TABLE 4. Overall Responses for Physically Intimidating Bullying

Never Now and Monthly Weekly Daily
Item Wording Has a Nurse Ever (%) Then (%) (%) (%) (%)
Shouted at you or made you the target of their spontaneous anger 52.2 29.6 4.4 1.8 1.1
Demonstrated intimidating behaviors towards you such as pointing their
nger at you, invading your personal space, shoving you, or blocking 68.8 16.4 4.0 0.7 0.4
your view or way
Threatened violence against you or physically abused you 88.5 0.4 0 0 0

e152 Journal of Surgical Education  Volume 71/Number 6  November/December 2014

(20.8%), helplessness (7.1%), and depression (5.8%) at a
statistically higher proportion than nonharassed residents.26
From an employers perspective, workplace bullying results
in an increased number of sick days,27 high turnover,28 low
productivity,29 and burnout.29 In fact, nurses with less than
3 years of experience demonstrated decreased productivity
with just a single act of workplace bullying.29 Just as new
nurses struggle with adapting to the stressful situations of a
new job, health care hierarchy, and unmanageable work-
loads,29 so do residents.30 Yet the effect of workplace
bullying on general surgery residents is unknown.
Our study has several limitations. First, we did not receive a
response from every general surgery program. In our effort to
protect condentiality, we had a limited population and a
possible selection bias among those completing the survey.
Despite sending out 2 reminders, the response rate was low.
Our results may not translate to the entire general surgery
resident population. Our survey only involved surgical resi-
dents, and as such, our results may be not hold true across
different residency disciplines. We did not specically dene
the term nurse and left the interpretation up to the
respondent, so our results may be different when asking
about specic nursing populations such as operating room
nurses or nurse practitioners. In addition, our results may be
subject to recall bias, as we asked the respondents to recall the
frequency of events in the past, which may be underreported
or overreported. Finally, our survey tool was one-sided, in
that, we did not ask nurses the frequency with which they
were subjected to negative acts. Certainly, the reverse is
equally important in forming a collaborative health care team
to promote patient safety and professionalism. It is likely that
the nurses have experienced workplace bullying at the hands
of surgical residents too and possibly to a greater extent.
CONCLUSION
Workplace bullying of general surgery residents by nurses does
occur. Understanding the triggers, circumstances, and variables
that affect the bullying may help us to create preventative
strategies. We do not know how workplace bullying affects the
residents well-being, nurse, health care team, and care of the
patient. Future research should be directed toward these goals
to improve professionalism and patient safety. These data may
help to create programs that will educate health care profes-
sionals on how to recognize workplace bullying and techniques
to deter and handle workplace bullying and to care for not
only the patients but also for each other.
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