Content uploaded by Lyn Quine
Author content
All content in this area was uploaded by Lyn Quine on Feb 07, 2016
Content may be subject to copyright.
Special Section:
Praxis: Ethical Issues in Medical Education and Training
Workplace Bullying, Psychological Distress,
and Job Satisfaction in Junior Doctors
LYN QUINE
Workplace bullying has been recognized as a major occupational stressor since
the mid 1980s.
1,2,3
A number of different terms have been used to describe it,
including employee abuse,
4
emotional abuse,
5
mistreatment and neglect at
work,
6
mobbing,
7,8
and harassment.
9
In the United Kingdom, a number of
reports from trades unions illustrating the pain, psychological distress, physical
illness, and career damage suffered by the victims of bullying first drew
attention to the issue.
10,11,12
However, academic interest in the issue began only
recently, and there are still few empirical studies. The most systematic research
comes from Scandinavia, where there is strong public awareness and antibul-
lying legislation.
13,14
In the school-based literature, bullying is defined as a subset of aggressive
behaviors involving three criteria: it is intentional harm-doing, involves an
imbalance of power between the victim and the bully, and is carried out
repeatedly and over time.
15
Three main types are identified: direct physical
bullying, verbal bullying, and indirect bullying. Definition of workplace bully-
ing presents the researcher with significantly more difficulties, for there is no
clear agreement on what constitutes adult bullying, whether it refers to a range
of behaviors or can be expressed in a single definition. Physical bullying is
rarely reported,
16
but the workplace presents unique opportunities for a wide
range of aggressive and intimidating behaviors. Most existing definitions incor-
porate three elements. First, in line with case-law definitions in the related
areas of racial and sexual harassment, the perceptions of the behavior by the
victim, not the intention of the perpetrator, determines whether bullying has
occurred. Thus it is subject to differences in personal perceptions. Second, there
must be a negative effect on the victim.
17
See for example, one of the most
widely used definitions, that of the U.K. Manufacturing, Science, and Finance
Union (MSF):
persistent, offensive, abusive, intimidating, malicious or insulting behav-
iour, abuse of power or unfair penal sanctions, which makes the
recipient feel upset, threatened, humiliated or vulnerable, which under-
mines their self-confidence and which may cause them to suffer stress.
(p. 3)
18
Thirdly, the bullying must be persistent. The rule of thumb used in Sweden, for
example, is one occurrence per week over the last six months.
19
Five categories of bullying behavior have been identified in the literature:
20
Cambridge Quarterly of Healthcare Ethics (2003), 12,91
–
101. Printed in the USA.
Copyright © 2003 Cambridge University Press 0963-1801/03 $12.50
91
• threat to professional status
—
belittling you in public, professional humil-
iation, accusation of lack of effort
• threat to personal standing
—
spreading rumors, gossiping about you, name
calling, and teasing
• isolation
—
ignoring you, withholding information from you, preventing
access to opportunities such as leave or training
• enforced overwork
—
undue pressure to produce work, setting impossible
deadlines, unnecessary disruptions
• destabilization
—
failure to give credit when due, being given meaningless
tasks, removal of responsibility, shifting of goalposts, repeated reminders
of error
Bullying is most frequently associated with an abuse of power, by a line
manager or supervisor over junior staff. However, other power relationships
may lead to bullying by colleagues or a group of people who may target one
individual.
In the United States, a parallel literature has indicated that medical students
and trainee doctors also report experiencing high levels of mistreatment or
bullying behaviors. In 1982, a U.S. physician, Henry Silver, drew attention to a
transformation in attitude and behavior that took place among students over
the course of medical school training, from “eager and enthusiastic” to “cyni-
cal, depressed, and filled with frustration,” and suggested that these changes
could be the result of abuse or mistreatment that was unrecognized or ignored.
In a later paper, Silver and Glicken reported the results of the first empirical
study of the incidence and severity of abuse in one medical school.
21
A number
of other studies quickly followed describing the types of mistreatment suf-
fered.
22,23,24,25,26,27,28,29,30,31,32
A survey of ten U.S. medical schools in 1991, for
example, found that 96% of medical students had suffered abuse: 87% reported
public belittlement and humiliation, 81% being shouted or yelled at, 55% sexual
harassment, 36% being given extra tasks for punishment, 34% being threatened
with unfair grades, 19% racial harassment, and 18% being hit or pushed.
33
It is
now recognized that high levels of mistreatment occur, which increase with
progression through medical school, continue during the early postgraduate
years,
34
are a significant source of stress, and may be an important cause of
dropout.
35,36
The literature suggests that such treatment is often justified in
terms of its “educational” value. Kassebaum and Cutler observe that the most
common forms of mistreatment
—
public belittlement and humiliation
—
appear
to be “misguided attempts to reinforce learning.”
37
Both mistreatment of medical students and workplace bullying have been
linked to a host of adverse effects on the health and well-being of those who
experience it, including depression, anxiety, lowered job satisfaction, greater
sickness absence, higher propensity to leave, and reduced effectiveness at
work.
38,39,40,41,42,43
Increased smoking and escape drinking have also been
reported.
44,45,46,47
One issue that makes the study of bullying difficult is inherent in the way it
is defined. Because bullying or mistreatment are normally assessed by self-
report, the question inevitably arises as to whether some people’s perceptions
may be biased due to dispositional traits, leading them to be more likely to
report benign behavior as bullying. In previous work, I drew attention to a
likely source of bias
—
negative affectivity
48
—
defined by Watson and Clarke as
Lyn Quine
92
a mood dispositional dimension that reflects stable and pervasive individual
differences in negative emotionality and self-concept. In an influential review,
these authors concluded that individuals high in negative affectivity “are more
likely to report distress, discomfort, and dissatisfaction over time and regard-
less of the situation.” Such individuals also tend to dwell on their failures and
shortcomings and to focus more on the negative aspects of other people and
the world in general. “Consequently they have a less favourable view of self
and other people and are less satisfied with themselves and life” (p. 483).
49
Findings from this and further reviews
50,51
suggest that it would be appropriate
to take account of negative affectivity when investigating reports of bullying.
Though there has been considerable research on the mistreatment or abuse of
medical students in the United States, there is little research on trainee doctors
either in the United States or the United Kingdom. Additionally, the influence
of negative affectivity on reports of bullying and on relationships between
bullying and occupational health outcomes has not been investigated. This
study aimed to bridge that gap. The study arose after the issue of bullying was
raised with the author by a Dean Director of Postgraduate Medical Training in
the United Kingdom, following publication of a paper in the British Medical
Journal on bullying among health professionals.
52
The aims were to investigate
the prevalence of bullying among junior doctors, to determine the association
between workplace bullying and demographic variables such as age, gender,
and ethnic group, and to examine the relationship between bullying and two
occupational health outcomes, job satisfaction and psychological distress after
partialing out the effects of negative affectivity.
Methods
An anonymous questionnaire was sent out with the BMA News Review to a
sample of 1,000 junior hospital doctors with job grades from house officer to
senior registrar, randomly generated electronically from the British Medical
Association members’ mailing list. The News Review is sent out regularly to all
registered doctors. Because of the method of contacting participants, it was not
possible to send reminders. After 2 months, the data were entered onto
computer and analyzed using SPSS for UNIX.
Questionnaire
The questionnaire was in three sections. The first collected information about
the participant’s age, gender, job grade (house officer, registrar, etc), and ethnic
group. The second section contained two widely used scales to measure
occupational health outcomes, psychological distress (GHQ-12),
53
job satisfac-
tion,
54
and a measure of negative affectivity.
55
The GHQ-12 is a self-
administered questionnaire for detecting psychiatric disorder in a British
population. It is a shortened 12-item version of the General Health Question-
naire designed by Goldberg.
56
The job satisfaction scale is an 18-item measure
produced by Brayfield and Rothe to measure facet-free job satisfaction.
57
The
Negative Affectivity Scale provides a 21-item measure of negative affectivity.
All three scales are widely reported to have satisfactory reliability and validity.
The third section of the questionnaire contained questions about junior
doctors’ experiences of bullying. The Lyons et al. definition of bullying, which
Workplace Bullying in Junior Doctors
93
has been endorsed by trades unions, was presented.
58
Participants were then
asked to indicate whether they had been subjected to workplace bullying in the
last 12 months and whether they had witnessed others being bullied. Partici-
pants also completed a 21-item bullying scale developed for our earlier work,
which asked about experience of 21 bullying behaviors from peers, senior staff,
or managers in the past 12 months.
59
Results
We received 594 completed questionnaires, and 48 were returned undelivered
by the postal service, which represented a response rate of 62%. As a first step,
scores were computed for job satisfaction, GHQ-12, and negative affectivity.
Each scale was found to have good internal reliability, with Cronbach’s alphas
of 0.92 for job satisfaction, 0.90 for GHQ-12, and 0.81 for negative affectivity.
Table 1 shows the participants’ job grade, gender, and ethnic group. Fifty-five
percent of the respondents were house officers or senior house officers, whereas
39% were registrars, 3% were senior registrars, and 3% held other junior
grades. The sample was equally divided between men and women. Seventy
percent were white, and 30% were from other ethnic groups.
Prevalence of Bullying
Overall, 37% (220) junior doctors reported having been bullied in the past 12
months. Sixty-nine percent (407) had witnessed the bullying of others. Fifty-
three percent (107/211) reported being bullied by colleagues in their own work
group, 46% (91/199) by people outside their own work group, 60% (123/205)
by their immediate team leader, 34% (66/194) by a senior manager, and 30%
(46/154) by some other person. Ninety-six percent (212/220) of doctors reported
being bullied by more than one person.
Associations between Bullying and Demographic Variables
To investigate differences in reports of bullying by gender, ethnic group, job
grade, and age, analyses by chi-square test were conducted. The results showed
that doctors from minority ethnic groups were more likely to report being
Table 1. Profile of Participants
Job grade (n 5 589)
House officer/senior house officer 321 (55%)
Registrar/specialist registrar 230 (39%)
Senior registrar 18 (3%)
Other 20 (3%)
Gender (n 5 590)
Male 294 (50%)
Female 296 (50%)
Ethnic group (n 5 587)
White 413 (70%)
Other ethnic group 174 (30%)
Lyn Quine
94
bullied than white doctors (45% [78] compared to 34% [139]; df 1, x
2
5 5.9, p ,
0.05; CI 1.11
–
2.28), and women were more likely to report being bullied than
men (43% [126] compared to 32% [92] of male doctors; df 1, x
2
5 7.2, p , 0.01;
CI 1.14
–
2.26). There were no differences in reports of bullying by age or job
grade. There were no significant differences in negative affectivity between
men and women or between white doctors and those from minority ethnic
groups, showing that variations in negative affectivity could not account for the
significant findings. Overall, negative affectivity accounted for only 6% of the
variance in reports of bullying (R2 5 0.059, F(1,556) 5 36.0; p , 0.001).
Prevalence of Bullying Behaviors
Table 2 shows the proportion of junior doctors reporting each type and
frequency of bullying behavior and the proportion of doctors from minority
ethnic groups compared to white doctors. Eighty-four percent of doctors (486)
had experienced at least one type of mistreatment. Table 3 presents the differ-
ences in gender between those who reported each type of bullying behavior
and those who did not.
Associations between Bullying and Occupational Health Variables
To examine whether doctors who reported being bullied suffered lower levels
of job satisfaction and greater psychological distress than other doctors and to
ensure that these relationships were unrelated to negative affectivity, analyses
of covariance were conducted. Two separate analyses, one for job satisfaction
and one for psychological distress, were conducted using negative affectivity as
a covariate. The results showed that even when negative affectivity was
partialed out, doctors who reported being bullied had significantly lower levels
of job satisfaction (adjusted mean 61.5 versus 64.9, t(1, 523) 5 8.1, p , 0.001;
95% CI 20.23
–
0.38) and higher levels of psychological distress (adjusted mean
4.0 versus 2.7, t(1, 551) 5 10.6, p , 0.001; 95% CI 0.15
–
0.10) than those who did
not report it.
Discussion
Thirty-seven percent (220) of junior doctors in this study reported being bullied
in the previous year. Negative affectivity accounted for only 6% of the variation
in such reports. These rates compare with 18% reporting being bullied in the
last 6 months in a recent UNISON survey of trade union members and 38% in
the previous 12 months in a study of 1,100 staff in a community National
Health Service Trust.
60,61
Both of these studies were carried out in the United
Kingdom. Though a little over a third of doctors identified themselves as
having been bullied, 84% of doctors had actually experienced at least one type
of bullying behavior. These most often took the form of destructive innuendo
and sarcasm (43%), persistent attempts to belittle and undermine an individu-
al’s work (40%), or undue pressure to produce work (39%), although persistent
and unjustified criticism of work (37%), public humiliation (34%), and shifting
the goalposts (32%) were frequently reported.
Estimates of harassment, abuse, and discrimination among both medical
students and junior doctors in the United States are generally somewhat higher,
Workplace Bullying in Junior Doctors
95
Table 2. Overall Rates of Bullying Behaviors and Differences by Ethnic Group
All White
Other
ethnic groups x
2
Threat to professional status
Persistent attempts to belittle and undermine your work 232 (40%) 149 (37%) 78 (45%) 3.5*
Persistent unjustified criticism and monitoring of your work 213 (37%) 151 (38%) 57 (33%) 1.1 NS
Persistent attempts to humiliate you in front of colleagues 198 (34%) 131 (33%) 63 (37%) 0.8 NS
Intimidatory use of discipline/competence procedures 101 (17%) 66 (16%) 33 (19%) 0.7 NS
Threat to personal standing
Undermining your personal integrity 174 (30%) 120 (30%) 51 (30%) 0.0 NS
Destructive innuendo and sarcasm 250 (43%) 170 (42%) 77 (45%) 0.3 NS
Verbal and nonverbal threats 107 (18%) 66 (16%) 39 (23%) 3.2 NS
Making inappropriate jokes about you 166 (28%) 99 (25%) 59 (34%) 5.7 **
Persistent teasing 122 (21%) 89 (22%) 31 (18%) 1.2 NS
Physical violence 2 (0%) 0 (0%) 0 (0%)
——
Violence to property 10 (2%) 6 (2%) 4 (2%) 0.5 NS
Discrimination on grounds of race or gender 88 (15%) 35 (9%) 50 (29%) 39.4 ***
Isolation
Withholding necessary information from you 114 (20%) 71 (18%) 42 (24%) 3.4 NS
Freezing out/ignoring/excluding 179 (31%) 115 (29%) 61 (36%) 2.7 NS
Unreasonable refusal of applications for leave, training, or promotion 142 (24%) 83 (21%) 56 (33%) 9.4 **
Overwork
Undue pressure to produce work 356 (39%) 138 (34%) 81 (47%) 8.2 **
Setting of impossible deadlines 179 (31%) 119 (30%) 58 (34%) 0.9 NS
Destabilization
Shifting goalposts without telling you 188 (32%) 131 (33%) 53 (31%) 0.2 NS
Constant undervaluing of your efforts 164 (28%) 110 (27%) 49 (29%) 0.1 NS
Persistent attempts to demoralize you 96 (17%) 61 (15%) 33 (19%) 1.4 NS
Removal of areas of responsibility without consultation 73 (13%) 54 (13%) 19 (11. ) 0.5 NS
NS 5 Not significant
*p , 0.05
**p , 0.01
***p , 0.001
96
Table 3. Differences in Reported Bullying Behaviors by Gender
Males Females x
2
Threat to professional status
Persistent attempts to belittle and undermine your work 100 (32%) 128 (44%) 5.4 *
Persistent unjustified criticism and monitoring of your work 95 (33%) 114 (40%) 2.7 NS
Persistent attempts to humiliate you in front of colleagues 79 (27%) 115 (40%) 10.0 ***
Intimidatory use of discipline/competence procedures 42 (15%) 57 (20%) 2.6 NS
Threat to personal standing
Undermining your personal integrity 63 (22%) 109 (38%) 17.1 ***
Destructive innuendo and sarcasm 107 (37%) 141 (49%) 7.6 **
Verbal and nonverbal threats 47 (16%) 58 (20%) 1.3 NS
Making inappropriate jokes about you 66 (23%) 92 (32%) 5.6 **
Persistent teasing 60 (21%) 60 (21%) 0.0 NS
Physical violence 2 (1%) 0 (0%) 2.0 NS
Violence to property 8 (3%) 2 (1%) 3.7 NS
Discrimination on grounds of race or gender 44 (15%) 40 (14%) 0.1 NS
Isolation
Withholding necessary information from you 60 (21%) 54 (19%) 0.4 NS
Freezing out/ignoring/excluding 86 (30%) 91 (32%) 0.8 NS
Unreasonable refusal of applications for leave, training, or promotion 72 (25%) 68 (23%) 0.2 NS
Overwork
Undue pressure to produce work 111 (39%) 109 (38%) 0.0 NS
Setting of impossible deadlines 86 (30%) 91 (31%) 0.1 NS
Destabilization
Shifting goalposts without telling you 89 (31%) 95 (33%) 0.2 NS
Constant undervaluing of your efforts 64 (22%) 96 (33%) 8.5 **
Persistent attempts to demoralize you 34 (12%) 60 (21%) 8.2 **
Removal of areas of responsibility without consultation 40 (14%) 33 (12%) 0.8 NS
NS 5 Not significant
*p , 0.05
**p , 0.01
***p , 0.001
97
though measured over a longer time period. For example, Richman et al. found
that 89% of graduates reported experiencing some form of harassment during
their time at medical school, whereas Baldwin et al. reported a figure of 96%,
and Wolf et al. 99%.
62,63,64
Daugherty et al., in a survey of bullying in the first
postgraduate year, found a figure of 93%.
65
Junior doctors from minority ethnic
groups were more likely to be bullied and reported five bullying behaviors
significantly more frequently than white doctors. These findings are consistent
with findings in the United States.
66,67
Although this should be a cause for
concern, it should not come as a surprise. Racial discrimination has been shown
to occur at all levels in the U.K. medical profession, from application to medical
school
68,69,70
to examination success,
71
job application,
72,73,74,75
and even the
allocation of distinction awards to consultants.
76
Women doctors were more
likely than men to be bullied and reported seven of the 21 bullying behaviors
significantly more frequently. These findings are in accord with those from a
study of university employees, which found that women experience work
harassment more often and more severely than men.
77
Junior doctors were
most likely to have been bullied by their immediate team leader, which is
consistent with the idea that it is an ill-conceived attempt to reinforce learning.
78
Those who had experienced bullying reported decreased job satisfaction and
increased psychological distress, even when negative affectivity had been
covaried out, which suggests that negative affectivity does not play any
significant role in these relationships and should not be used as an explanation
by those seeking to deny the existence of bullying. The reports of other doctors
who have witnessed bullying, though have not themselves been bullied, also
suggests that bullying is not simply in the eye of the beholder. The notion that
those who report bullying are simply those who view the world through
gloomier spectacles places the victims in double jeopardy, because it both
denies their own perceptions of their experience and precludes any discussion
of the health consequences that bullying may have.
The interpretation of these findings should be guarded. Like all the U.S.
studies, this one relied on self-reports of bullying, which are by definition
subjective and may not entirely correspond to the actual occurrence of mis-
treatment. People’s perceptions about what constitutes bullying or their per-
sonal sensitivity and vulnerability to mistreatment or abuse may differ.
Nevertheless, the literature on stress emphasises that it is people’s appraisals of
stressful events that are important rather than the events per se (pp. 22
–
94).
79
We have tried to minimize the effects of bias by providing a clear definition of
bullying, asking about individual bullying behaviors and controlling for neg-
ative affectivity in some analyses. A second reason for caution is that the data
are cross-sectional, which limits the conclusions that can be drawn about cause
and effect relationships. Prospective longitudinal data that would monitor
reports of bullying and subsequent negative effects are now needed. A final
limitation is the nonresponse rate. Although a higher rate would have been
desirable, the study achieved an acceptable response rate of 62%, which is
similar to many other studies of mistreatment (Baldwin et al. 59%; Wolf et al.
61%; Mangus et al. 55%; Komaromy et al. 62%).
80,81,82,83
Despite these limitations, the data presented here strongly suggest that
disturbingly high levels of bullying and mistreatment during training are a part
of many junior doctors’ perceptions and experience. The price of ignoring it
may be dropout from medical school, high levels of anxiety and depression
Lyn Quine
98
among trainee doctors, ignoring the needs of patients, and future mistreatment
of others by those who have been mistreated
—
the so-called transgenerational
legacy.
84,85,86
The development and implementation of antibullying policies that
include a statement on expected standards of behavior, education to raise
awareness of bullying, the introduction of procedures for dealing with allega-
tions of bullying, and protection of the accusers from retaliation would seem to
be important steps forward. These are beginning to be implemented in the
United Kingdom,
87
although they seem to have had little effect in the United
States, where, after two articles had aroused national attention,
88,89
the Amer-
ican Medical Association recommended that all medical schools should imple-
ment measures to combat bullying.
90
According to Kassebaum and Cutler,
however, despite these measures, the pattern of student abuse is largely
unabated.
91
It appears that alongside changes in policy, what is required is a
change in attitudes and in the mistaken conviction that negative rather than
positive reinforcement best promotes learning.
Notes
1. Zapf D, Leymann H. Mobbing and victimization at work. European Journal of Work and
Organizational Psychology 1996;5(2):whole issue.
2. Hoel H, Rayner C, Cooper CL. Workplace bullying. In: Cooper CL, Robertson LT, eds.
International Review of Industrial and Organisational Psychology. New York: Wiley; 1999:195
–
230.
3. Quine L. Workplace bullying in NHS community trust: staff questionnaire survey. BMJ
1999;318:228
–
32.
4. Bassman E. Abuse in the Workplace. New York: Quorum Books; 1992.
5. Keashly L. Emotional abuse in the workplace: conceptual and empirical issues. Journal of
Emotional Abuse 1998;1:85
–
117.
6. Price-Spratlen L. Interpersonal conflict which includes mistreatment in a university workplace.
Violence and Victims 1995;10:285
–
97.
7. Leymann H. The content and development of mobbing at work. European Journal of Work and
Organizational Psychology 1996;5(2):165
–
84.
8. Niedl K. Mobbing and well-being: economic and personnel development implications. Euro-
pean Journal of Work and Organisational Psychology 1996;5(2):239
–
49.
9. Brodsky CM. The Harassed Worker. Toronto: Lexington Books; 1976.
10. Manufacturing Science Finance. How Big Is the Problem of Bullying at Work? Report of a Survey of
MSF Workplace Representatives on Their Experiences and Impressions of Bullying at Work. London:
Manufacturing Science Finance, 1995.
11. UNISON. Violence at Work: Health Service Staff Study. London: UNISON; 1995.
12. NASUWT. No Place to Hide: Confronting Workplace Bullies. Birmingham, Ala.: NASUWT; 1996.
13. Leymann H, Gustavsson B. Psychological Violence at Workplaces: Two Exploratory Studies. Stock-
holm: Arbetarskyddsstyrelsen; 1984.
14. Leymann H. Mobbing and psychological terror at workplaces. Violence and Victims 1990;5(2):119
–
26.
15. Olweus D. Bullying in Sweden. In: Smith PK, Morita Y, Junger-Tas J, Olweus D, Catalano R,
Slee P, eds. The Nature of School Bullying. London: Routledge; 1999:11.
16. See note 3, Quine 1999.
17. Rayner C, Hoel H. A summary review of literature relating to workplace bullying. Journal of
Community and Applied Social Psychology 1997;7:181
–
91.
18. Lyons R, Tivey H, Ball C. Bullying at Work: How to Tackle It. A Guide for MSF Representatives and
Members. London: Manufacturing Science Finance; 1995.
19. Vartia M. The sources of bullying: psychological work environment and organisational climate.
European Journal of Work and Organizational Psychology 1996;5(2):203
–
14.
20. See note 17, Rayner, Hoel 1997:183.
21. Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. JAMA
1990;263(4):527
–
32.
22. Wolf TM, Randall HM, von Almen K, Tynes LL. Perceived mistreatment and attitude change by
graduating medical students: a retrospective study. Medical Education 1991;25:182
–
90.
Workplace Bullying in Junior Doctors
99
23. Kleinerman MJ. Elucidating and eradicating medical student abuse. JAMA 1992;267(5):738
–
42.
24. Sheehan KH, Sheehan DV, White K, Leibowitz A, Baldwin DC Jr. A pilot study of medical
student “abuse”: student perceptions of mistreatment and misconduct at medical school. JAMA
1990;263(4):533
–
7.
25. Baldwin DC Jr, Daugherty SR, Eckenfels EJ. Student perceptions of mistreatment and harass-
ment during medical school: a survey of ten United States schools. Western Journal of Medicine
1991;155:140
–
5.
26. Richman JA, Flaherty JA, Rospenda KM, Christensen ML. Mental health consequences and
correlates of reported medical student abuse. JAMA 1992;267(5):692
–
4.
27. Bourgeois JA, Kay J, Rudisill JR, Bienenfeld D, Gillig P, Klykylo WM, et al. Medical student
abuse: perceptions and experience. Medical Education 1993;27:363
–
70.
28. Uhari M, Kokkonen J, Nuutinen M, Vainionpaa L, Rantala H, Lautala P, et al. Medical student
abuse: an international phenomenon. JAMA 1994;271(13):1049
–
51.
29. Richardson DA, Becker M, Frank RR, Sokol RJ. Assessing medical students’ perceptions of
mistreatment in their second and third years. Academic Medicine 1997;72(8):728
–
30.
30. Daugherty SR, Baldwin DC Jr, Rowley BD. Learning, satisfaction, and mistreatment during
medical internship. JAMA 1998;279(15):1194
–
9.
31. Mangus RS, Hawkins CE, Miller MJ. Prevalence of harassment and discrimination among 1996
medical school graduates: a survey of eight U.S. schools. JAMA 1998;280(9):851
–
3.
32. Kassebaum DG, Cutler ER. On the culture of student abuse in medical school. Academic
Medicine 1998;73(11):1149
–
58.
33. See note 25, Baldwin, Daugherty, Eckenfels 1991.
34. See note 32, Kassebaum, Cutler 1998.
35. See note 23, Kleinerman 1992.
36. See note 24, Sheehan, Sheehan, White, Leibowitz, Baldwin 1992.
37. See note 32, Kassebaum, Cutler 1998:1150.
38. See note 3, Quine 1999.
39. Bjorkqvist K, Osterman K, Hjelt-Back M. Aggression among university employees. Aggressive
Behaviour 1994;20:173
–
84.
40. Vartia M. Bullying at workplaces. In: Lehtinene L, Rantanen S, Juuti P, Koskela A, Lindström R,
Rehnström P, et al., eds. Towards the 21st Century: Work in the 1990s. Proceedings from the
International Symposium on Future Trendings in the Changing Working Life. Helsinki: Institute of
Occupational Health; 1991:131
–
5.
41. Matthiesen SB, Raknes BI, Rökkum O. Mobbing på arbeidsplassen [Bullying at work]. Tidsskrift
for Norsk Psykologforening 1989;26:761
–
74.
42. Kivimaki M, Elovainio M, Vahtera J. Workplace bullying and sickness absence in hospital staff.
Occupational and Environmental Medicine 2000;57:656
–
60.
43. Einarsen S, Raknes BI. Mobbing in Worklife: A Study of the Prevalence and Health Effects of Mobbing
in Norwegian Workplaces. Bergen, Norway: Forksningscenter for arbeidsmiljö (FAHS), University
of Bergen; 1991.
44. See note 3, Quine 1999.
45. See note 23, Kleinerman 1992.
46. See note 26, Richman, Flaherty, Rospenda, Christensen 1992.
47. See note 43, Einarsen, Raknes 1991.
48. See note 3, Quine 1999.
49. Watson D, Clarke LA. Negative affectivity: the disposition to experience aversive emotional
states. Psychological Bulletin 1984;96:465
–
90.
50. Watson D, Pennebaker JW. Health complaints, stress and distress: exploring the central role of
negative affectivity. Psychological Review 1989;96:234
–
54.
51. Clarke LA, Watson D. General affective disposition in physical and psychological health. In:
Snyder CR, Forsyth DR, eds. Handbook of Social and Clinical Psychology. New York: Pergamon;
1991:221
–
45.
52. See note 3, Quine 1999.
53. Goldberg D. General Health Questionnaire (GHQ-12). Windsor, United Kingdom: NFER-Nelson;
1992.
54. Brayfield AH, Rothe HF. An index of job satisfaction. Journal of Applied Psychology 1951;35:307
–
11.
55. Stokes JP, Levin IM. The development and validation of a measure of negative affectivity.
Journal of Social Behavior and Personality 1990;5(2):173
–
86.
Lyn Quine
100
56. Goldberg D. General Health Questionnaire (GHQ-60). Windsor, United Kingdom: NFER-Nelson;
1978.
57. Rayner C. The incidence of workplace bullying. Journal of Community and Applied Social
Psychology 1997;7:199
–
208.
58. See note 18, Lyons, Tivey, Ball 1995.
59. See note 3, Quine 1999.
60. See note 3, Quine 1999.
61. See note 57, Rayner 1997.
62. See note 22, Wolf, Randall, von Almen, Tynes 1991.
63. See note 25, Baldwin, Daugherty, Eckenfels 1991.
64. See note 26, Richman, Flaherty, Rospenda, Christensen 1992.
65. See note 30, Daugherty, Baldwin, Rowley 1998.
66. See note 39, Bjorkqvist, Osterman, Hjelt-Back 1994.
67. See note 40, Vartia 1991.
68. McManus IC, Richards P, Winder BC, Sproster KA, Styles V. Medical school applicants from
minority ethnic groups: identifying if and when they are disadvantaged. BMJ 1995;301:469
–
500.
69. McManus IC. Factors affecting likelihood of applicants being offered a place in medical schools
in the United Kingdom in 1996 and 1997: retrospective study. BMJ 1998;317(7166):1111
–
7.
70. Esmail A, Nelson P, Primarolo D, Toma T. Acceptance into medical school and racial discrim-
ination. BMJ 1995;301:501
–
2.
71. Dillner L. Manchester tackles failure rate of Asian students. BMJ 1995;310:209.
72. Esmail A, Everington S. Racial discrimination against doctors from ethnic minorities. BMJ
1993;306:691
–
2.
73. Esmail A, Everson D. Editorial. Tackling racism in the NHS: we need action not words. BMJ
1997;314(7081):618.
74. McKeigue PM, Richards JD, Richards P. Effects of discrimination by sex and race on the early
careers of British medical graduates during 1981
–
7. BMJ 1990;301(6758):961
–
4.
75. Commission for Racial Equality. Appointing NHS Consultants and Senior Registrars: Report of a
Formal Investigation. London: Commission for Racial Equality; 1996.
76. Esmail A, Everington S, Doyle H. Racial discrimination in the allocation of distinction awards?
analysis of list of award holders by type of award, specialty and region. BMJ 1998;316(7126):193
–
5.
77. See note 39, Bjorkqvist, Osterman, Hjelt-Back 1994.
78. See note 38, Kassebaum, Cutler 1998.
79. Lazarus RS, Folkman J. Stress, Appraisal and Coping. New York: Springer; 1984.
80. See note 22, Wolf, Randall, von Almen, Tynes 1991.
81. See note 25, Baldwin, Daugherty, Eckenfels 1991.
82. See note 37, Mangus, Hawkins, Miller 1998.
83. Komaromy M, Bindman AB, Haber RJ, Sande MA. Sexual harassment in medical training. New
England Journal of Medicine 1993;328:322
–
6.
84. See note 23, Kleinerman 1992.
85. See note 24, Sheehan, Sheehan, White, Leibowitz, Baldwin 1990.
86. See note 26, Richman, Flaherty, Rospenda, Christensen 1992.
87. Hicks B. Time to stop bullying and intimidation. Hospital Medicine 2000;61:428
–
31.
88. See note 21, Silver, Glicken 1990.
89. See note 24, Sheehan, Sheehan, White, Leibowitz, Baldwin 1990.
90. American Medical Association. Teacher-Learner Relationship in Medical Education. AMA Policy
H-295-955. Chicago: American Medical Association; 1990.
91. See note 38, Kassebaum, Cutler 1998.
Workplace Bullying in Junior Doctors
101
