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This week Lieutenant General David Morrison AO has been invited to my healthcare network to discuss bullying and harassment.  Before considering it in the medical profession, it is worth looking over what bullying means to children.

Bullies have been around since before school even began. Many examples from page to screen have struck fear into all of us – be they Gripper Stebson, Biff Tannen or Draco Malfoy.

Cady: [narrating] Calling somebody else fat won’t make you any skinnier. Calling someone stupid doesn’t make you any smarter. And ruining Regina George’s life definitely didn’t make me any happier. All you can do in life is try to solve the problem in front of you  

Mean girls  (2004)

Bullying can occur in many forms. Whilst it is often physical, it can also be emotional. It can occur in person in the playground or anonymously through the internet. In the medical text, it is defined as:-

“intentional, unprovoked abuse of power by one or more children to inflict pain or cause distress to another child on repeated occasions”

How common is bullying?

It is hard to get accurate figures at it is so often under-reported but at least 5-15% of primary school aged children and up to 10% off adolescents are victims of bullying on a weekly basis, with boys more likely to be involved than girls. These figures are based on Finnish data. Australian data suggested that up to 23.7% of students bullied others on a weekly basis and around 12.7% of children are victims. Incidence  does seem to decrease with age though with much less going on in senior school, despite what television would have us believe

What sorts of bullying go on?

The majority is verbal in nature – name calling and teasing. This covert bullying may be accompanied by whispers and blackmailing. Only a small proportion involves overt physical violence.

Cyberbullying – doing so by electronic means – presents unique challenges, though research suggests that victims of cyber abuse are also more likely to be victims of traditional bullying. Cyberbullies are more likely to be older due to the ease of access to technology. One of the biggest challenges of online bullying is that it does not require the perpetrator to be present, and so is with the victim 24/7, even if they are in a traditional place of safety – the family home.

Bully and victim represent primitive archetypes for which there are stereotypical behavioural patterns. Bullies are seen as aggressive and dominant whilst lacking empathy. Victims are (perhaps) introverted, with self-esteem issues and a tendency to blame themselves for events outside their control.

victim

Bullying rarely occurs in isolation. It occurs in groups. According to Sutton and Smith, those who witness the behaviour may belong to a number of participant roles.

Assistants – join in the ribbing

Reinforcers – laugh and point fingers, providing social reinforcement and positive feedback

Outsiders – stay away and don’t take sides, but their lack of condemnation may be seen as silent approval

Defenders – are anti-bullying and stand up to be counted

Perhaps this generalised diffusion of social responsibilities that can occur in a crowd (otherwise known as the bystander effect) might account for the high proportion of outsiders.

RoleSixth gradeEighth grade
No clear role12.7%8.2%
Defender17.3%19.6%
Outsider23.7%32.0%
Reinforcer19.5%15.2%
Assisstant6.8%10.8%
Bully8.2%8.5%
Victim11.7%5.7%

Looking at this table of participant roles in grade 6 and 8 children, we can see that participant role allocation seems stable and does not vary wildly with increasing age.  It would suggest that any intervention to change the role to that of defender would require group participation. Some methods proposed are:-

General awareness training

Identifying the various participant roles strikes the heart of the matter – the participants’ self-concept. Students may not be aware of how they have been encouraging bullying, even if they deny they have been.  Talking about group conformity makes it clear that everyone is responsible, not just the bully or the assistant.

Self-reflection

Class members should be allowed to reflect on their roles in bullying situations to see where they fit in the group. By viewing dramatised acts of bullying in a safe setting, they can reflect and work towards change.

Rehearse better behaviour

It’s not enough for someone to recognise that something needs to be done; students must be given the appropriate tools to change their behaviour. This may involve role-playing to evoke empathy as well as general assertiveness training.  Psychologists have shown that a carefree attitude on the victim’s part is more likely to stop bullying. Conversely, an attitude of helplessness or even retaliation is more likely to fuel the flames.

What are the potential causes of bullying?

Many doctoral theses have been written on the origins of bullying.  Let’s break down some of the candidates.

Developmental theory

Those of you that have toddlers are fully aware of their desire/need to assert their authority over all they survey. Like a mini Joffrey, they lash out at anything and anyone, especially those smaller than them (the cat, for instance). As they get a little older, they see this as a normal way to act to get the attention they deserve.  Some would suggest that power-assertive child-rearing techniques may also lead to the modelling of inappropriate behaviour.

It is much more likely a multi-factorial problem.

Psychological theory

We’ve covered briefly stereotypical patterns above. Victims are often introverted, with low self-esteem and a lack of assertiveness.  Whether this is a result of or caused by bullying is difficult to tease out. This does not mean that all introverts with low self-esteem are victims or that all un-empathic children become bullies. It does mean that it is possible to identify some of the more vulnerable children and equip them with more effective social skills.

Olveus proposed the concept of the passive or submissive victim – the person is seen as weak and will not retaliate and the provocative victim – the sort that gets easily irritated and hyperactive due to bullying.

Sociocultural theory

We have a social niche based on culture, gender, race and ethnicity. Recent presidential nominations aside, we live in a predominantly patriarchal society with the Joffrey’s preying on the Sansa Starks and feeling culturally justified in their oppression of girls/women. Does this account for why boys are much more likely to become bullies than girls and why they are more likely to bully girls than boys?

This “construction of hegemonic masculinity” is also posited as a reason why boys lacking in stereotypical masculine behaviour may be bullied more often.

Sociocultural theory may also account for bullying along ethnic or racial divides.  Those cultures that have fallen victim to colonial expansion are more likely to be bullied, perhaps by the process of cultural transmission. Certainly, Aboriginal children are more likely to be bullied by their non-indigenous peers, but this does not seem to be valid outside of Australia.

Peer group pressure theory

Rather than breaking things down by gender or race, this theory suggests that bullying is a local cultural response to the ethos of the group or school. Small groups band together to protect themselves from the threat of the outsider. In this sense, bullying is not performed by individuals but by a group or mob. Bullies may see themselves as not to blame for their actions.  This can be difficult to counteract, but utilising the group towards a comm, on the goal of shared concern, may stamp out the unwanted activity.

Dan Olweus has done a huge amount of research in this area, looking at data from over 130,000 questionnaire datasets. His data has also helped bust a few myths about bullying.  It does not depend on class or school size (though more prominent schools and classes have a proportionally higher absolute number of bullies and victims).  There was no association between poor grades and bullying activity. And finally, there appears to be no link between external appearance (freckly, wearing glasses, being overweight) and bullying.

What happens to the bullies?

According to one popular behavioural theory, bullying may be part of a larger cluster of problem behaviours, including disliking school, smoking and drinking to excess. These individuals are liable to take anti-social conduct into adult life. They are more likely to have criminal convictions and be involved in serious crimes.

What happens to the victims?

Victims of bullying may suffer from a wide range of psychological, psychosomatic and behavioural problems. This role may be replayed throughout many scenarios in later life as their feelings of chronic adversity and lack of social support lead to further psychological consequences such as depression.

They may present to the general practitioner, emergency department or general paediatrician with a number of symptoms that are not easily explained away including:-

A thoughtful and thorough HEADSS screen may pick these up, but explicitly asking questions about traditional and online bullying is worthwhile.

Although it has not been systematically studied, low self-esteem and depression, brought on by peer victimization, may lead to increased risk of self-harm or suicide among adolescents.

It must also be remembered that some bullied students also go on to bully others.  These boys (because they are invariably male) often rated highly for the presence of psychosomatic symptoms – such as headaches or dizziness – during periods of bullying.

The National Schools Safety Framework sets about a set of guiding principles that reflect the fact that all schools are supposed to safe, respectful and supportive communities.

Bottom line

Bullying is much more prevalent than you would think, especially in primary school-aged children.  The short and long-term impacts on the victim’s psychological and bodily health need to be considered.

Having read this post about bullying in children, I’d like you to indulge me and go over it again and think of the bullies and victims, not at school, but in your place of work. In light of recent findings in Ballarat changing culture becomes even more important.

Who is David Morrison?

Former Chief of Army Lieutenant General David Morrison AO (Ret’d) is an outspoken opponent of gender bias and discrimination. He is famous for this speech…

https://youtu.be/QaqpoeVgr8U

“The standard you walk by is the standard you accept”

What do we mean by workplace bullying?

In this post I am going to concentrate on bullying rather than sexual harassment. Though I absolutely do not want to make light of this very important topic, as a privileged white male it is not something I have first hand experience of. Others, including the erudite Ash Witt, have a much better feel for this.

In this discussion bullying means discrimination, unjustified criticism, verbal threats, undue pressure and having jokes made at someones expense.

How common is it?

Despite legislation bullying and harassment is endemic within the culture of medicine. It is unlawful to treat someone differently on account of their sex, age, race, age or because they are pregnant or disabled.

A survey of the Australian medical workforce over 2008-2009 reported that a quarter of respondents had suffered from repeated episodes of bullying and harassment. Senior doctors (including consultants and registrars) were the perpetrators in 44% of cases.

It must also be remembered that doctors are not the only bullies (or victims) in the healthcare system. All strata of hospital life may be involved – from higher managers to nurses and orderlies – nobody is immune.

Is it specialty dependent?

The recent RACS EAG reported that surgical trainees have a markedly higher incidence of bullying than those in medical specialties. In a similar way that childhood bullying may be, in part, due to socio-cultural expectations, the increased incidence of bullying among surgeons may be due to its roots in a patriarchal hierarchy.

No specialty is immune to bullying though general practitioners experience lower levels than non-GPs. This may between junior GP’s an their supervisors or between practice managers and reception staff.

Is it related to year of qualification?

One landmark study from 1990, reported in JAMA, found that 46.4% of students at one medical school had suffered bullying at one point or other during their training and by the time they had finished it was up to 80.6%. If such a high percentage of students leave medical school as victims of abuse does this set up doctors to become perpetrators of a cycle of abuse in a horrific bastardization of the old “See one, Do one, Teach one” model of pedagogy?

For those of us that supervise medical students it is worth considering this. Ignoring them or telling them to go away continues the negative cycle. It’s not the professional behaviour that we want to instill in those coming in to the profession.

What is it about the workplace culture that allows bullying to continue?

When I wrote about bullying in schools I talked about the participant roles of bystanders. As well as the bullies and victims there are:-

The assistants are the Crabbe and Goyle to the bullying Malfoy. They join in the fun and help out with the bullying. Whilst the bully is often readily identifiable in the workplace the assistants are not so common.

The re-inforcers laugh and point fingers , providing social reinforcement like the rest of House Slytherin. At work these are may be the rest of the firm that laugh at the consultants inappropriately sexist or racist jokes. These ethical chameleons (according to Brainard) agree with everything their seniors tell them, cut corners and cover up minor errors and because of this, unfortunately, are seen as more professional than those who display honesty.

The Outsiders try and keep away and say nothing. Their silence acts as tacit approval of the act of bullying -most of Harry’s classmates.  Who are the outsides in the workplace?  Sad to say this role is the one most of us fall into. Perhaps out of fear or ignorance we do not stand up when we should.

Defenders take a stand against what is wrong, comfort and try to stop the bullies. There is no better example of this than Hermione and Ron. Bullying and inappropriate behaviour will always exist unfortunately.

What impact does bullying and harassment have?

On the individual

We’ve already talked about the impact of bullying on individuals when talking about schoolchildren.  In adults it may also lead to psychological harm with poor self-esteem, anxiety and depression lading to an increased risk of suicide. It may also impact on a person physically with higher rates of sick leave in victims.

On the workplace

Aggressive behaviour has been linked with poor transfer of information and trouble within teams. This is not good for patients. The larger impact that bullying has is that it normalizes it and so Outsiders are less likely to speak out.

What can be done about it?

When we looked at data from bullying in children we saw that there was little change in bullying year on year unless a system wide intervention takes place and no change in participant roles unless there is a culture change. Moving the victimized student into a new class does not solve the problem.

With most involved in the bullying process (even as Outsiders) then interventions need to be directed towards changing the group and not the individual.

AMA Victoria is helping develop the AMA Standard that will set the benchmark for workplace behaviour. The cornerstones of this will be:-

  • Raised awareness
  • Accountability and voice
  • Training and education
  • Alignment

As seniors we must be sensitive to the cries of our junior colleagues. Many of us have had no formal training in receiving or handling complaints and so we should ask our healthcare trusts to provide us with all of the resources we need to handle such issues in a non-judgemental manner, acting as advocates for those that need up.

Bottom line

It is okay to speak up and speak out. If you witness bullying, in any off its forms, it is your moral duty to pluck up the courage of Neville Longbottom and stand up for what is right.

Resources

Bullying – No Way – the Australian governments official anti-bullying site

Reach Out – Practical support for young people going through tough times

Beyond Blue – This excellent online resource is primarily related to depression and anxiety

Bully Blocking

References

Askew DA, Schluter PJ, Dick ML, Régo PM, Turner C, Wilkinson D. Bullying in the Australian medical workforce: cross-sectional data from an Australian e-Cohort study. Australian health review. 2012 May 25;36(2):197-204.

Brainard AH, Brislen HC. Viewpoint: learning professionalism: a view from the trenches. Academic Medicine. 2007 Nov 1;82(11):1010-4.

Forero R, McLellan L, Rissel C, Bauman A. Bullying behaviour and psychosocial health among school students in New South Wales, Australia: cross sectional survey. BMJ. 1999 Aug 7;319(7206):344-8.

Kaltiala-Heino R, Rimpelä M, Rantanen P, Rimpelä A. Bullying at school—an indicator of adolescents at risk for mental disorders. Journal of adolescence. 2000 Dec 31;23(6):661-74.

Perren S, Dooley J, Shaw T, Cross D. Bullying in school and cyberspace: Associations with depressive symptoms in Swiss and Australian adolescents. Child and adolescent psychiatry and mental health. 2010 Nov 23;4(1):1.

Olweus D. Bullying at school: basic facts and effects of a school based intervention program. Journal of child psychology and psychiatry. 1994 Oct 1;35(7):1171-90.

Rigby K. Addressing bullying in schools: Theory and practice. Australian Institute of Criminology;; 2003 Jun 1.

Salmivalli C. Participant role approach to school bullying: Implications for interventions. Journal of adolescence. 1999 Aug 31;22(4):453-9.

Salmivalli C, Karhunen J, Lagerspetz KM. How do the victims respond to bullying?. Aggressive behavior. 1996 Jan 1;22(2):99-109.

Silver HK, Glicken AD. Medical student abuse: incidence, severity, and significance. Jama. 1990 Jan 26;263(4):527-32.

Sutton J, Smith PK. Bullying as a group process: An adaptation of the participant role approach. Aggressive behavior. 1999 Jan 1;25(2):97-111.

Witt, A. (2015, March 8). Medical Admission Note. Retrieved July 31, 2016, from https://www.ashleighwitt.com/2015/03/its-not-lady-doctor-its-doctor.html

About the authors

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5 thoughts on “Playground behaviour”

  1. Don’t forget that children who are being badly bullied can also be ill.. Parents may often attribute recurrent physical symptoms to the bullying. I saw a child with recurrent fainting.. parents convinced was due to bully & wanted letter to take to school principal.. ECG showed WPW. Don’t forget clinical basics.

  2. Firstly, I’d like to upvote this article on the basis that it includes a quote from Mean Girls.
    Secondly, I think at heart we are herd based mammals, and we seek out a rigid social hierarchy very early in childhood.
    I think often bullying isn’t done by deep cruelty, but rather that instinctive urge kids have to find their place in the pack, whether to establish self as an alpha or prevent yourself from being on the bottom rung.
    Preventing that tribal behaviour is hard, as reflected in your comments about the behaviour going into adulthood.
    Thanks for the article,

    1. Thanks Ben.
      Sometimes it takes a while for me to come up with an appropriate cultural reference. I was thinking about Tom Brown’s Schooldays, or Oliver Twist but then I thought, why not go for what you know – the oeuvre of Rachel McAdams.

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