The cultural and contextual differences make the definition of workplace bullying (WPB) difficult. However, it could be defined as the circumstances, in which the employee is a victim of aggressive or negative acts at work, principally psychologically with the impact of humbling, threatening, frightening, or harming the employee.
Healthcare practitioners are not immune to WPB. For example, in the United States, the abuse rates of nurses and doctors were 21.9/1000 and 16.2/1000 employees, respectively. Moreover, about 34.5% of emergency department staff are exposed to physical bullying and 71.6% are victims of confrontational verbal abuse. In an Iranian medical center experience, 44.4% were bullied annually. WPB is the result of many factors. It mainly involves a vulnerable victim, a bystander, and a undeterred perpetrator.
Surgical environments are especially prone to bullying. First, because the hierarchy is well respected. Second, many surgeons refuse to speak against their colleagues for fear of retaliation. Third, the surgical environment is extremely stressful, be it the operating room, trauma center, or even when discussing cases at conferences. Surgeons even bully under the pretext of being patient advocates. Junior doctors and residents who have observed bullying could themselves in future become bullies. This is particularly so if the bully is considered successful in their field.
A study conducted in Australia in 2019 showed that 47% of training and practicing surgeons were victims of bullying, while another 68% had witnessed bullying. A US Bullying Workplace Survey conducted in 2007 by the WPB Institute revealed that 49% of surgeons were either victims of bullying or had witnessed bullying at their workplace. Most of these surgeons later developed posttraumatic stress disorder. In 2018, a systematic review conducted to measure the differences between the prevalence of bullying in different countries concluded that in certain countries such as Australia and the UK, the prevalence is high, 49.3% and 53.8%, respectively. In Japan, however, the prevalence of bullying was low, with 27.6% of the respondents.
Unfortunately, in healthcare environments, WPB has an adverse effect on teamwork performance, threatens integrity, and negatively affects patient care. WPB also increases the incidence of medical errors, resulting in adverse outcomes. Besides, these negative acts also limit the care of patients. WPB reduces the commitment of healthcare professionals and makes staff absenteeism and increased burnout rates more likely. Recently, the Saudi Ministry of Labor introduced new rules which came into effect on October 20, 2020, to reduce the incidence and prevalence of WPB.
We conducted a cross-sectional study to assess the prevalence of WPB in surgical environments in multiple regions in Saudi Arabia. Surgical environments are replete with many situations that induce stress, which result in bullying of their colleagues and/or their patients by surgeons. Although different studies have assessed bullying among healthcare professionals, this is the first to assess WPB among surgeons in Saudi Arabia.
Materials and Methods
This was a cross-sectional study conducted between February 24 and August 24, 2021, among surgeons, trainees, interns, nurses, and students in surgical specialties in multiple Saudi regions using a self-administered questionnaire. Ethical approval was obtained from the Institutional Review Board (IRB) vide Letter No. IRB-2021-01-061 dated 18/02/2021 and written informed consent was taken from all the participants. All information were kept confidential, and the data were used for the proposed research. A validated tool known as the ‘’Negative Attitude Questionnaire-Revised (NAQ-R)’’ posted through Survey Monkey was used to collect the participants’ answers. The questionnaires were distributed through WhatsApp and Telegram groups of surgeons, surgical trainee, surgical nurses, and students rotating in surgical specialties.
NAQ-R is composed of 22 questions, in which bullying is described in terms of behavior rather than a direct use of the term “bullying,” to avoid influencing participants’ response. Bullying is a subjective term, the threshold of its acceptance differing from person to person. Questions are associated with negative behavior relating to person-related negative acts, work-related, and physical intimidation. Each question is answered on a scale, out of 5 points based on its frequency. The grading is as follows: one is never, now and then is two, monthly is three, weekly is four, and daily is five. The final question directly asks about bullying based on the definition. Demographics were also gathered. All levels of the Saudi healthcare system in all Saudi regions were sent an invitation to participate in our study.
Statistical analysis was done by the Statistical Package for the Social Sciences (SPSS) version 21 software (SPSS Inc., Chicago, IL, USA). The percentages and frequencies for all variables were calculated. Chi-squared test was applied to look for any relationship between variables. P < 0.05 was considered statistically significant. A cumulative score of NAQ-R < 33 was considered as not bullied, the score between 33 and 45 meant bullied infrequently, and above 45 were targets of frequent bullying at the workplace.
A total of 788 respondents participated in the study on the exposure to bullying at work, person-related or the subject of physical bullying during the past 12 months. We noticed that most participants had chosen the answer never, followed by the answer “now” and “then” to all questions except to the question of being at the receiving end of excessive testing and sarcasm in the person-related category. The percentage of answers “monthly”, “weekly”, and “daily” came in the third, fourth, and fifth order, respectively, except to a question in the person-related category which concerned having insulting or offensive remarks made about one’s person, attitudes, or private life, 46 (5.8%) said “weekly,” and 26 (3.3%) said “monthly” [Table 1].
The description of demographic characteristics, including age, gender, nationality, position, and specialty, is illustrated in Table 2. Approximately two-thirds of the participants, 514 (65.2%), were male, and about a third, 274 (34.7%), were female. Most (67.8%) were aged 20–29 years and only 36 (4.6%) participants were aged above 50 years. Of the 788 respondents, 695 (86%) were Saudis, and 93 (11.8%) were non-Saudi. Students were in the majority with 314 participants (39.8%), while the smallest group of 71 (9%) was that of interns. There were varied levels of participant contributors: 38.1% were undergraduates, 55 (7.0%) were interns, and 26 (3.3%) from anesthesia. The remainder were from different surgical specialties such as orthopedics, pediatric, and cardiac surgery and so were grouped together because of low responses. General surgery was the highest with 140 (17.8%) and ophthalmology the lowest at 30 (3.8%).
Regarding the geographical distribution demonstrated in Figure 1, 238 (30.2%) was the contribution from Makkah province, 127 (16.1%) from the Riyadh province, and 30 (3.8%) from the Qassim province. Consultants were the largest group as perpetrators of a negative act in the past 12 months with 349 (44.3%), followed by specialists with 232 (29.4%), 173 (22%) residents, 163 (20.7%) students, and nurses with 52 (6.6%).
Out of 788 participants, most responses (40.7%) indicated that they had never been bullied or been the recipients of such treatment in the past 12 months. On the other hand, 25 (3.2%) participants had been bullied daily. Moreover, 269 of the participants had never been witnesses to the bullying of other people, while 233 (29.6%) had witnessed this every now and then [Table 3].
With regard to reporting to authority if they had been exposed to bullying, only 172 (21.8%) said “yes,” 174 (22.1%) said they “hadn’t been exposed to bullying,” 220 (27.9%) said that “reporting the issue would make the situation worse,” 71 (9%) felt “not be supported if they reported,” and 41 (5.2%) said “the behavior stopped and didn’t re-occur.”
The range of NAQ-R score was from 22.00 to 110.00 (mean = 42.47, standard deviation = 17.9), which indicates that bullying of the participants was infrequent.
The Chi-square test reported a significant association between mean NAQ-R score regarding age, specialty, and position (P = 0.007, 0.002, and < 0.001, respectively), where the age category of 20–29, and interns were more frequently bullied than other participants [Table 2].
The statistical analysis reported no significant association of mean NAQ-R score regarding the geographic area (P = 0.097) but reported a significant association between mean NAQ-R score regarding reporting authorities (P < 0.001) [Table 4]. There was a significant association between nationality and age group regarding reporting authorities (P = 0.001 and < 0.001, respectively). Similarly, a significant association was seen between positions regarding reporting authorities (P < 0.001) [Table 5].
Surgery is a vital part of healthcare and a cornerstone in managing many conditions. Unfortunately, WPB could affect the surgeon by diminishing their self-confidence and questioning their ability to provide care.WPB affects nurses, adversely affects patient’s health, and creates a toxic workplace environment for the organization. There are three types of negative WPB that health workers face: that which occurs in the workplace, that which occurs on a personal level, and that which involves physical violence. This study aimed to assess the prevalence of WPB in surgical environments in different regions in the Saudi healthcare system.
In this study, students formed the majority of participants compared with surgeons, trainees, and nurses. Students who participated were rotating in surgical specialties in different centers in various regions of Saudi Arabia. The results showed that 47.6% of our participants, in many surgical environments, had been bullied during the last 12 months, with a NAQ-R score of 42.47, indicating that the participants had been bullied infrequently. Our results match the Ling et al’s study of 2016, which reported the prevalence of WPB in general surgery as 47%, with a NAQ-R score of 38%. This is supported by such other studies as Nabi et al., 2013, in which 49.3% of participating consultants and trainee surgeons had been bullied.
However, Crebbin et al., 2015, showed that Japanese doctors rotating in surgical specialties had reported a lower prevalence of bullying, 27.6%. Moreover, the literature suggests that bullying is often visible, since most surgeons had observed unprofessional behavior such as bullying.
The present result revealed a statistically significant relationship of demographic characteristics of participants, namely age, position, and specialty with WPB. This is in line with Awai et al., (2021) and Borges et al., (2015) who reported a significant association between age and WPB, whereby junior doctors were more likely to be bullied than senior doctors. On the other hand, Norton et al (2017), Baburajan et al (2019), Hassan ME (2021), and Ariza-Montes et al (2013) findings are not in accord with our results.
Consultants and surgical trainees are perpetrators of negative acts toward each other. The bullying happens vertically (attending to resident) and horizontally (resident to resident, attending to attending). This finding reveals a culture of bullying not only in surgical environments but also in the entire health sector. Similar to the Australasian College of Surgeons findings, which reported that attending faculty were the most likely to bully, our results revealed that consultants were the major offenders (44.3%). At a private college of medicine in Lahore, Mukhtar et al., (2010) reported that faculty members were the main perpetrators of bullying, especially of medical students. However, Timm (2014) who interviewed over a hundred medical students in the UK stated that senior faculty were mostly responsible (44.0%). The reasons for this pattern of bullying are complex. Sometimes, negative feedbacks are viewed as “bullying.” Some people even think of harassment as an effective method in the education of surgical trainees.
Although many studies are interested in studying WPB in surgical environments, to the best of our knowledge, no study has focused on studying the association between mean NAQ-R score of demographics including age, gender, nationality, and the position of reporting authorities on bullying in participants’ workplace. This was our focus in the study, and we revealed a significant association of reporting authorities on mean NAQ-R score, age group, nationality, and position. Therefore, we recommend that more studies should be conducted to address similar issues in different regions around the kingdom and elsewhere.
There are recognized limitations to this study. This cross-sectional study could not confirm direct relationships. Although the questionnaire (NAQ-R) had been validated, it might have been prone to bias since it was self-reported, and acceptance of Hofstede’s theorem might have led to an underestimation of the prevalence of bullying. The nonrepresentative demographics of the study participants and the use of nonprobability sampling do not allow the generalization of the results of this study.
The Illing report from England recommended dissecting bullying interventions to prevent bullying before it takes place, managing bullying when it takes place, aiding targets to heal, and bullies to reassess their behavior. Senior leaders’ role is critical to the success of any new interventions, specifically in supporting decisions taken, role-modeling, and maintaining the change. Recently approved regulations to protect individuals’ dignity, privacy, and personal freedom by the Saudi Minister of Labor and Social Development have been put into effect since October 20, 2020. Measures by the committee that investigated workplace harassment and the definition of workplace harassment form part of the solution put into effect by the Ministry.
Persistent negative acts are well known, especially within surgical environments in the Saudi healthcare system. Consultants and specialists are the offenders in bullying, implying that bullying is pervasive in the healthcare system. The challenge is to find and introduce solutions that would have a positive effect on the toxic culture of WPB. Teamwork and hard work at all levels are required to lessen the pervasive this problem. This study could be the starting point of investigating the applicability and usefulness of interventions to minimize WPB.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Einarsen S, Hoel H, Notelaers G Measuring exposure to bullying and harassment at work: Validity, factor structure and psychometric properties of the negative acts questionnaire-revised Work Stress 2009 23 24 44
2. O' Rourke M, Wrigley C, Hammond S Violence within mental health services: How to enhance risk management Risk Manag Healthc Policy 2018 11 159 67
3. Afshari Saleh L, Niroumand S, Dehghani Z, Afshari Saleh T, Mousavi SM, Zakeri H Relationship between workplace
violence and work stress in the emergency department J Inj Violence Res 2020 12 183 90 [doi: 10.5249/jivr.v12i2.1526]
4. Cantone E, Piras AP, Vellante M, Preti A, Daníelsdóttir S, D'Aloja E, et al. Interventions on bullying and cyberbullying in schools: A systematic review. Clinical practice and epidemiology in mental health CP EMH 2015 11 Suppl 1 M4 58 76
5. Srivastava R Speaking up – When doctors navigate medical hierarchy N Engl J Med 2013 368 302 5
6. DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, et al. Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues JAMA 2010 304 187 93
7. Halim UA, Riding DM Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaviour and harassment in the surgical workplace
Br J Surg 2018 105 1390 7
8. Pei KY, Cochran A Workplace
bullying among surgeons-the perfect crime Ann Surg 2019 269 43 4
9. Kelly S Workplace
bullying: The silent epidemic N Z Med J 2004 117 U1125
10. Bjørkelo B, Einarsen S, Matthiesen SB Predicting proactive behaviour at work: Exploring the role of personality as an antecedent of whistleblowing behaviour J Occup Organ Psychol 2010 83 371 94
11. Al Omar M, Salam M, Al-Surimi K Workplace
bullying and its impact on the quality of healthcare and patient safety Hum Resour Health 2019 17 89
12. Srabstein JC, Leventhal BL Prevention of bullying-related morbidity and mortality: A call for public health policies Bull World Health Organ 2010 88 403
13. Hogh A, Hoel H, Carneiro IG Bullying and employee turnover among healthcare workers: A three wave prospective study J Nurs Manag 2011 19 742 51
anti-harassment rules to be in force from Oct. 20 - Saudi Gazette
15. AlMulhim AA, Nasir M, AlThukair A, AlNasser M, Pikard J, Ahmer S, et al. Bullying among medical and nonmedical students at a university in Eastern Saudi Arabia J Family Community Med 2018 25 211 6
16. Mohamed AG Work-related assaults on nursing staff in Riyadh, Saudi Arabia J Family Community Med 2002 9 51 6
17. Al-Shamlan NA, Jayaseeli N, Al-Shawi MM, Al-Joudi AS Are nurses verbally abused? A cross-sectional study of nurses at a university hospital, Eastern Province, Saudi Arabia J Family Community Med 2017 24 173 80
18. Alsaleem SA, Alsabaani A, Alamri RS, Hadi RA, Alkhayri MH, Badawi KK, et al. Violence towards healthcare workers: A study conducted in Abha City, Saudi Arabia J Family Community Med 2018 25 188 93
19. Nagata-Kobayashi S, Maeno T, Yoshizu M, Shimbo T Universal problems during residency: Abuseand harassment Med Educ 2009 43 628 36
20. Ling M, Young CJ, Shepherd HL, Mak C, Saw RP Workplace
bullying in surgery World J Surg 2016 40 2560 6
21. Crebbin W, Campbell G, Hillis DA, Watters DA Prevalence of bullying, discrimination and sexual harassment in surgery in Australasia ANZ J Surg 2015 85 905 9
22. Nabi H, Harley S, Murphy E The perils and triumphs of night surgical residents across South Australia J Surg Educ 2013 70 265 72
23. Wu S, Zhu W, Li H, Lin S, Chai W, Wang X Workplace
violence and influencing factors among medical professionals in China Am J Ind Med 2012 55 1000 8
24. Arianayagam R, Rashid P Bullying among urology trainees in Australia and New Zealand: Lessons from a cross-sectional survey ANZ J Surg 2015 85 499 500
25. Harries RL, Gokani VJ, Smitham P, Fitzgerald JE Councils of Association of Surgeons in Training and British Orthopaedic Trainees Association. Less than full-time training in surgery: A cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce BMJ Open 2016 6 e010136
26. Awai NS, Ganasegeran K, Abdul Manaf MR Prevalence of workplace
bullying and its associated factors among workers in a Malaysian public university hospital: A cross-sectional study Risk Manag Healthc Policy 2021 14 75 85
27. Borges E, Ferreira TD Bullying no trabalho: Adaptaç ão do Negative Acts Questionnaire Revised (NAQ R) em enfermeiros Rev Port Enferm Saúde Ment 2015 25 -33.
28. Norton P, Costa V, Teixeira J, Azevedo A, Roma-Torres A, Amaro J, et al. Prevalence and determinants of bullying among healthcare workers in Portugal Workplace
Health Saf 2017 65 188 96
29. Baburajan C, Arasu S, Naveen R Prevalence of bullying among nurses in a tertiary hospital, Bangalore Int J Occup Safety Health 2019 9 8 12
30. Hassan ME Workplace
bullying among nurses in primary healthcare centers in port said Port Said Sci J Nurs 2021 8 163 83
31. Ariza-Montes A, Muniz NM, Montero-Simó MJ, Araque-Padilla RA Workplace
bullying among healthcare workers Int J Environ Res Public Health 2013 10 3121 39
32. Keeley PW, Waterhouse ET, Noble SI Prevalence and characteristics of bullying of trainees in palliative medicine Palliat Med 2005 19 84 5
33. Mukhtar F, Daud S, Manzoor I, Amjad I, Saeed K, Naeem M, et al. Bullying of medical students J Coll Physicians Surg Pak 2010 20 814 8
34. Timm A ‘It would not be tolerated in any other profession except medicine’: survey reporting on undergraduates' exposure to bullying and harassment in their first placement year BMJ open 2014 Jul 1 4 7 e005140
35. Garling PR Final report of the special commission of inquiry into acute care services in Sydney, NSW public hospitals, 2008
36. Illing JC, Carter M, Thompson NJ, Crampton PE, Morrow GM, Howse JH, et al. Evidence synthesis on the occurrence, causes, consequences, prevention and management of bullying and harassing behaviours to inform decision making in the NHS