You are not alone - Episode 4: Bullying and harassment

Shevonne Matheiken: The Psychiatric Trainees' Committee of the Royal College of Psychiatrists is proud to present "You Are Not Alone", a podcast series looking at the well-being of healthcare professionals. There is a lot more talk about wellbeing since the pandemic began, but wellbeing is complex, dynamic, and personal. It is not always something that can be resolved with just resilience training or mindfulness. Both those things are useful and have its place, but concepts such as intersectionality explain why there is so much more to consider while discussing the wellbeing of healthcare professionals. This is what we hope to achieve through our conversations. Episode 4, Bullying and Harassment.

Dr Niamh Sweeney: Hello, and welcome to this PTC podcast on bullying and harassment. My name is Dr Niamh Sweeney. I'm a PTC Rep in the North West and an ST5 in forensic psychiatry. Bullying and harassment are unacceptable behaviors in any workplace yet these are prevalent throughout the healthcare system. The negative consequences are far-reaching, not only affecting individuals but entire workforces, undermining training, and ultimately compromising patient care.

I am joined today by Mr. Simon Fleming and Dr Sridevi Kalidindi to discuss the impact of bullying and harassment on trainees. Simon is a registrar in trauma and orthopedic surgery in London. He has achieved national and international acclaim for his award-winning campaign "Hammer It Out", tackling bullying, undermining, and harassment in healthcare organizations. Sridevi is an award-winning senior consultant psychiatrist in London. She is also a leadership executive and life coach, national NHS clinical leader, ex-associate medical director, board trustee, and entrepreneur. Thank you both for joining us today to talk about this important topic.

Obviously, each situation is different and multilayered. I thought what would assist our conversation and give some context would be to have some anonymized real-life narratives of bullying and harassment. So first I start with one of the narratives.

 "A few years ago, I had some difficulties with my clinical supervisor. They were a new consultant and had a reputation already for believing trainees were useless until proven otherwise. I'd recently returned from a period of extended leave and found it very difficult to work alongside the consultant. “There were no big things, just lots of small comments and incidents. I felt like they didn't like me, and I remember having an extensive workload and being denied time to focus on other important non-clinical skills. I also wasn't sure how to escalate the problem as they were both my clinical and educational supervisor. In the end, I requested to be transferred to an alternative supervisor, but this was not supported by my TPD. Instead, I was asked to seek help from the PSW at the deanery, which reinforced my belief that the problem was mine." Simon, could I come to you first with your thoughts on this case?

Simon Fleming: I mean, that's-that's got layers to it, right? And I think this is important because often when you have these conversations it's so easy for people to write this off as a kind of abstract concept, but stories are so powerful, and that's a really common one. So obviously we don't know any details about the individual, but what I would say is that, you know, 80% of people who are less than full-time, uh, tend to be women. And that narrative is extremely common amongst, uh, women in training of, uh, returning from a time period away.

And-and this is, again, a not uncommon story in the sense that the-the consultant already had a reputation. And classically bullying doesn't have to be that big, explosive. You know, the days of-of orthopedic consultants throwing scalpels are mostly, not entirely, but mostly over. And actually, that one big explosive event tends not to be missed anymore, right? If-if a consultant held someone up against a wall words are going to be heard. And bullying's not about that. Bullying is simply about power and silence.

It doesn't have to be this huge display of power. It can be loads of little moments that chip away at you and-and make you feel, in some way, frightened, not respected, made fun of, upset, or to be fair, just less of a human being. The challenge is, number one, the classic thing, which is a trainee doesn't feel that they can raise concerns, and when they do, they're told either no or that it's them. It's some failing in them because by definition, of course, it can't be the consultant because they're a consultant.

And, of course, even that power dynamic, that hierarchy, that infantilization of us as, uh, human beings is part of the systemic problem. And the idea that you say, "Look, I'm really struggling with this person or this relationship or these behaviors," and to be told, "Well, bad luck. Maybe you need to go to the professional support network," again, is a failure of our system.

If I was going to be devil's advocate, if I was really going to have some fun, I would say, "Well, if this consultant has a reputation, I wonder why no one has ever spoken to them before." I talk a lot about professional conversations and how to have uncomfortable conversations, which is part of this. And one of the narratives I sometimes use is the, um, having a piece of food in your teeth. Like you don't really want to be told that you've been doing this and looking like a complete idiot.

And-and for the person telling you, it's absolutely awful to go, "I'm really sorry but can I--" You know, it's like telling someone they have body odor. But if someone has a reputation for being a bully, a bad trainer, making people cry, all that sort of stuff, these reputations don't come from nowhere. And you do have to wonder why nobody has gone, "Doctor so-and-so, could we have an informal chat over a cup of coffee about how you interact with people?"

The problem is we don't, at the moment, really have as a robust system as we might like for escalating these things. You know, I work with the GMC. I actually think they do an amazing job in the face of huge pressures. And their responsibility is to patients. But the GMC survey if I want to say I'm being bullied, I have to give up my anonymity immediately and then that information is given to my immediate supervisors who statistically are the most likely people to be the ones doing these things. So we need a better way of supporting trainees.

And this is the final thing is the problem we have as well is because our culture is so blame-based and not in any way focused around, um, change or learning, I would say that-that unsurprisingly lots of trainers are like, "Well, what now I can't give negative feedback?" And what we don't have yet is a culture whereby I say to you, um, you know, "Dr Sweeney, I think you're a trainee in difficulty," and you say, "Well, I think you're a bully."

And someone, ideally me, goes, "Yeah, they're not mutually exclusive. So actually I think it's probably going to be really useful if we have a conversation through whatever medium about how you're struggling, but it sounds like maybe I need to do some reflection, have some conversations about how I behave and feedback. It’s not one or the other.

But at the moment, we use words like bullying in lots of contexts as a weapon and it's why we can't move on to that learning and change-based system because it's so easy for someone to throw the word out because it's so emotive and so powerful without actually getting into the nitty-gritty, which is it's entirely possible that the trainee did have some problems and did need support and did need to go to the PSW. It is also entirely possible by the sounds of it that that trainer probably needs to have some conversations of their own.

Dr Sweeney: Thank you. Yes, some-some really important points there. You've mentioned things like blame and it being emotive, having to face the-the person face to face that you have, raised concerns about, possibly putting trainees off raising concerns. Are there any other barriers, do you think, to raising concerns about this kind of behavior?

Simon: Oh, yes and it's not even I think thing. Like we know we know that there are barriers. And the data comes from schools, from industry, from the military, and from healthcare. So the-the classic example is, if you look at the NHS Staff Survey, uh, about every year, 25% of staff in the NHS that fill out the survey, report bullying of some kind, right? And we know that these behaviors are under-reported. So I once convinced the GMC to put some questions into the GMC Survey about underreporting about these behaviors.

And there's been some work done, certainly among surgical trainees, in a more focused way about the same. And really it comes down to this, "The GMC concede that these behaviors are underreported." And the data they have suggests that about 1 in 20 don't report these behaviors for one reason or another but they're also willing to concede that underreporting is probably underreported for the same reasons. The three reasons are primarily; I don't want to make a fuss, I don't think it would make a difference, I think it will have some kind of detrimental effect on my career. And you can unpack those quite a lot, right?

"I don't want to make a fuss." What does that mean? Well, it means having to fill out forms, having to create drama, having to have really serious conversations with potentially very important, influential people. You're-you're not sure because of-- not just because of imposter syndrome but because of the culture we have of hierarchy and all the rest. "I don't think it'll make a difference" is huge, right? That is because we all know people who've raised concerns like the person in that scenario and have either been told, "Don't make a fuss. It's not them, it's you." Or there's been all the drama, there's been all this stuff, and nothing has changed.

Then, finally, it's the detrimental effect on your career. And it cuts both ways. Partly, it's because there's short-term career stuff, which is, you know, you're there for three to six months and it's going to be awful because now your consultant or your registrar or matron or whoever it is now knows that you've reported them, and they can make your life unpleasant or uncomfortable, and the fear that you'll get known as, you know, the troublemaker, the boat rocker.

And, you know, full disclosure, I am very proud of the work I've done. It started six years ago. And in that time, I have received explicit and more hidden threats, including death threats to me and my family. Certainly, to my career and you know, I have been told face to face, "You will never work in this city, hospital, specialty, whatever. You've ruined your career. You've burned all your bridges." And I am a pretty, you know, robust individual with a decent amount of grit and all those other kinds of terms that you probably understand a lot more than I do, but that's not easy to hear.

And to be fair, if you're not me, with all the privilege that I come with of being a straight white man, which means already I have certain protections in place because of the world. It's not surprising that if someone goes, "I wouldn't do that. That won't go well at ARCP." You go, "Yes, probably best not." So those three reasons when you start to unpack them become a very big story of why our system isn't set up to do this sort of work.

And, you know, the systems that we currently work in, and they are better than they were, but healthcare was not designed with speaking truth to power in mind. When you-when you look at, for example, the discrimination and harassment data, and we know that the most common forms of harassment are, around sex and gender, ethnicity and race, and, LGBTQ, you're already getting not only those single points of less privilege, if you like, those barriers that are in place.

But also, as soon as you start to introduce intersectionality, it's not surprising that people are like, "Yeah, it's not going to make a difference. I'm not going to stop this person being a homophobic racist any day soon. And to be fair, it's been hard enough getting where I am now without introducing more battles into my life. And I can't afford ARCP to go badly. And I really can't afford not to get a consultant job."

Dr Sweeney: So there's a huge power imbalance, isn't there? Which seems like that is really stifling for people who are in this kind of situation. And even more so, like you mentioned, if they've got those protected characteristics. Sridevi, is there anything you'd like to add?

Dr Sridevi Kalidindi: I mean I'd agree it's so multi-layered. And just unpacking that one issue, there are so many elements to it. I suppose some of the things I do want to say, firstly, it's never just about the individual, or even just the line manager. You know, these issues arise as part of a culture, you know, how systems have been set up. The sort of toxic triad that we think about as, "What is it that are individual factors?" And they may be protected characteristics. They may also be certain ways of thinking that the individual has developed over time that make them more susceptible to, you know, feel a certain way, or even behave a certain way. There are issues with the line manager, or, in this case, you know, the-the-the supervisor. Again, what is that person's schema? How do they look at the world? How do they see their trainees? And here we talked about somebody who already, you know, feels trainees are-- they're not good until they prove otherwise. So they're already seeing people through a filter that is unhelpful and sets people up to be bullied quite frankly.

You also then have the organisation that they work within. And the fact that this has been allowed to go on, it's known about, and nobody's actually dealt with it and spoken to that trainer and supervisor to say, "There might be a different way to do this." All of these things align. It is a trick triad, really, and we have to understand what's going on at each of those levels, I think, to really resolve these kinds of issues.

And we know about systems. You know, we have to look at all of the elements and deal with all of them. So how do we do that? It's not easy, but it can be done, and it needs to be done. You know, there's no-- I just feel like we've come to a point where we just need to stop making excuses and we need to get on and make these changes. It is life or death. It really is. It can be the life or death of the individuals who feel that they're bullied. We know how this ends up. In suicide for some people. And we also know about the life and death situations. That happens because we are all supporting patients. We're caring for patients.

And when the-the professionals are having issues and problems around bullying, that absolutely impacts patient care. It impacts patient safety. We know this. So, there is absolutely no excuse for any one of the people in the system to turn a blind eye. It's not acceptable. It's what we turn up to work for. So that said, I think there's a real shift that is happening, um, that needs to be accelerated. And it is this move from a kind of hero leadership, "It was a certain type of person." You know, white, middle, upper-class man, straight man, in those kinds of leadership roles.

And that fitted for most part. It's very different now. And we have to move with the time. So, there's something about that moving towards a much more compassionate leadership. And even a servant leadership. You know, we are here to serve. We're here to serve those that we train. We are here to serve our patients and the wider public. Coming to the issue of what it may be for the individual that is causing some of this.

Bullying is very subjective. You know, what is it maybe-- what is it that's making me feel frightened or put down or upset? What is it? So where can that reflection happen? That conversation. You know, where is the safe space to reflect on saying, "Is it just me? Is there something here"? And generally, there's going to be something there, but it is about the interaction with the individual, and the sort of wider culture.

So how can that person then reflect and get the support to think about, "What is it in my own way of thinking that isn't helping me here? And how can I manage it?" And, you know, I often will in my coaching talk to people about, even just using the kind of very simple CBT framework, there's a circumstance. Somebody is being rude to me or they're putting me down. What is happening, that's the circumstance. I have a thought about it that can then lead to an emotion that then leads to my action and leads to a result.

So, there is power in there for me as an individual if I can change my thought about it. It doesn't mean I'm rubbish. I'm not rubbish. Just because that person is being rude to me, you know, I can change the thought. I can then feel differently. So I don't have to feel worthless or useless. I can feel very much that actually, I'm, you know, good at my job. I may need some support. And then it's about what do I do with that and who can I trust.

And I think that is really difficult right now to understand, you know, the way that our landscape lies. And it is everybody's responsibility to deal with bullying. It should be happening on an individual basis. If I see somebody that I think is, you know, behaving in a manner that is bullying to take them aside and have that conversation. And I would say here, coaching skills are incredibly powerful because by asking a question of that person, you're asking them to reflect on their behavior, why they behaved in that way, what was it triggered it, but also what is the impact they're having on that other person?

And there's a phrase that I like to use is, "What is it like to be on the receiving end of me?" It's a very powerful question because if that trainer stopped to ask themselves, "What is it like to be on the receiving end of me?" They probably wouldn't like the answer. So just moving on to think about when people behave in this bullying way, there are often issues that they have that they have not dealt with. They need to reflect on what it is that's going on for them that they feel that this kind of behavior is acceptable.

A lot of that may be learned, it may be the way that they've through their childhood and growing up-- they've seen other people behaving towards others and getting their way. It may be the way that they have developed in interacting with others and getting their way. So where is it, that bringing people up and saying, "Actually, there's a different way. And how can we support you to behave differently"?

Dr Sweeney: Simon, you, um, had something to say in response to what Sridevi was talking about there?

Simon: Well, there was something that really resonated, and it's this great Maya Angelou quote, which is, "Do the best you can until you know better, but once you know better, do better." And when I reflect on my journey as a-as a person, I'm the first to admit that I have demonstrated all of these negative behaviors in the past. All of them. Every single one. And I think that's a big part of it. We can't wag the finger at people and-and beat them with a stick because for a lot of people, it was absolutely how they were trained and how previous people were trained. And more than just trained, they were explicitly told this is how it's done.

I think that's the point, is no one's expecting a magic wand and for everyone to suddenly become perfect humans. And I love that phrase of "What's it like to be on the receiving end of me?"

It's about creating a culture whereby you have to stop yourself and go, "Yeah, I know what I want to do but I probably shouldn't. I'm going to have to take a deep breath and I have to reflect on it because of that conversation I had over a cup of coffee," or "that conversation I had with my colleague or my supervisor. And I'm going to try and do slightly differently now because," and this is something that Sridevi said and I 100% agree with, "the time for debate about whether these things are bad and whether these things are happening is over. We know they are bad, and we know they are happening." So the next step is, "Now we know better, how can we do better?"

Dr Sweeney: Thank you. Yeah. And I think a lot of what you were saying about actually raising concerns and it being a patient safety issue, as well as just really uncomfortable for the individual and for the workforce who are experiencing is really, really important and leads on a little bit to, the next narrative that we've got.

"In my first post as a core trainee, I happened to be the only international medical graduate. I felt self-conscious but did my best to overcome this. I noticed I was treated very differently to the UK trainees, and I felt like a complete outsider. As this was my first post in the UK, I had no idea if this was just how things were or who to ask. I was also a minority in terms of ethnicity and religion, and I felt that these were contributing factors. It is only when I rotated to a different department that I realized the way I'd been treated was not right." Sridevi, can I ask you, uh, what your thoughts are on this?

Dr Sridevi: So an international medical graduate essentially being sort of excluded and bullied, because of who they were and some of their protected characteristics. So the first thing to say is that's illegal, and it needs to be recognized as such. The second point is, just imagine leaving all your family after working so hard. Medicine is hard on so many levels, academically, emotionally, coming to a different country and everything that goes with that. Probably, you know, the bravery really of that and being treated like that. I mean, it's disgraceful, isn't it? Really is disgraceful.

And they're coming to help our family, our friends, our society. Okay. So I think that's important to flag. And how many people actually think about it in that way? Not enough. Because that is what that person has done, and that's what they're doing. That's the first thing, I think to recognize. And then it comes to, "Why are people behaving in that way?" So some of it we've already touched on, but there's an element of this almost, you know, you're either in or you're out. And, you know, what does it do by excluding people?

It's showing lack of compassion. It's othering that person, which is almost kind of dehumanizing them in a sense. Is that about, you know, "I have to be in the in-crowd"? And that can be sometimes-- That's how bullies operate right often. If you think about it, you have to either be in with them in the in-crowd or you're the other person who can be bullied. So, for me, just thinking about our kind of human psychology around some of this, it's really terrible to not be in the tribe because what that means to us is that we are rejected. If we are rejected, we're going to be out there in the cold on our own.

So for somebody to go through that can key into their very primal fears and get the whole sort of fight, flight, freeze kind of scenario going on for that individual. So it is really serious. And it's about that personal understanding that and being able to manage it in a way that doesn't impact or reduces the impact to their mental health. And then it's also about the people who are effectively excluding and bullying that person to understand the impact of what they're doing.

So there's something about everybody understanding what bullying is because it's very sad that the trainee had to wait that whole six months or four months, whatever, however long it was, before they understood that this was actually bullying. So, I would say to all trainees, read the local policies and read the national policies on what bullying is so you can identify it. And particularly as somebody coming in as an international medical graduate, where often the power structures are even more hierarchical and actually bullying can be quite rife and accepted, and that's the way things are done, it may not be understood to be that when they come here to work here.

So one thing I do want to think about in this setting is incivility. And it's being talked about more and more, but the price of incivility in the workplace of not just being kind and considerate to one another. Uh, and I think again, how do we create cultures where that's the norm and anything outside of that is totally unacceptable? Whoever we are. Whether we're a consultant, whether we are the chief executive, whether we're a trainee.

Dr Sweeney: I think that's a really important point and I wondered if, Simon, you've got a lot to say about changing cultures and how do we safeguard against, bullying and harassment at work.

Simon: Yeah. And-and-and I think it's important to reiterate that in the UK bullying is not illegal. Being an unpleasant, disrespectful, rude person in the workplace is not illegal in this country. However, harassment and discrimination are. So harassment is basically when these behaviors are related to, disability, age, gender, pregnancy, maternity, race, religion, or belief, sex, and sexual orientation. And then discrimination is when you are treated unfairly because of the protected characteristics that exist.

And the fact is we have to understand that because those things aren't illegal and-and it, again, sometimes makes it very easy to write these things off of, "Well, you know, I'm just that guy, right? I sometimes I'm a bit hard and maybe I'm not always the nicest guy, uh, but it just is who I am." And it's just absolute tosh. And it's interesting that, you know, we-we raise the-the point of incivility. You know, incivility is a phraseology, if you like, for talking of about, uh, rudeness and nearly synonymous or homonymous with not treating people with respect.

It's important to labor that-that we're not saying be nice. Excessive niceness has been shown to be as harmful because excessively nice people don't raise concerns. They don't speak truth to power or truth to anyone. What we're saying is you can be firm, you can be stern even, you can give negative feedback and you can still be civil. You can still be polite and respectful. And it's because we know and we've addressed it before that-that these sorts of uncivil behaviors directly affect how be people behave, and therefore, we know that in our workplace they affect patient care.

It's the same data in banking and the military and everything else. It's just in our world, that means patients. So, we know that, you know, if someone is rude or disrespectful to me, about 80% of people will spend time in their day worrying about these behaviors. There'll be about a 40% reduction of my work quality and about a 50%, reduction in my time at work. I will take sick days or I will make sure I book every nanosecond of leave that I can just to not be there.

But interestingly, if I'm the recipient of these behaviors, this disrespect, this incivility, 25% of people will take it out on patients. But what's interesting is, if you witness it, so I walk past the-the person you described, experiencing an episode of racism, or sexism or whatever and I witness it, I as the witness will have a 20% decrease in my performance, a 50% decrease in my willingness to help others, which is interesting when you consider that nearly all of our work in the NHS is interdisciplinary and multidisciplinary. And I having witnessed that racism or sexism or whatever will have a 75% reduction in my, I think the phrase is kind of enthusiasm. My joy of coming to work.

So these behaviors have huge impacts on how we work together and how we work in the NHS. And, again, the problem we have is we were set up when we were set up as a tribal system. We are set up in loads of different silos. We are bred, We role model the us and them mentality. And what we've lost is the good bits of that. There is power in community. There is power in team. There is power in belonging, right? You know, the GMC did their report, and they talked about one of the things that doctors crave is a sense of belonging, but there's that fine line that we walk between, "If you don't belong, you are therefore not in the team."

And, of course, the narrative sounds like I'm saying, "Well, it's because you're not an orthopedic surgeon." "Oh, you're not psychiatry." "Oh, did you not train at Nottingham or London or Birmingham? You don't get the jokes." Right? But what we're actually saying for a lot of people is, "Oh, because you don't look like me because you're a person of color." "You don't sound like me because you didn't train in the UK." "You don't love the same people I love because you're a member of the LGBTQ community." And those behaviors are where it becomes toxic.

And we know from work with, international medical graduates, and we know from work with other kind of communities where these behaviors are rife, that it makes them feel really unsafe. It's scary coming to a new place to work. Its scary whether you are privileged up, the ying-yang like I am, or whether you are really the, you know, not. But if you imagine the difference between being scared, that first day at work jitters, those I don't know how to log onto a computer, I don't know where the toilets are, and I don't know what anyone's names are to potentially this is my second, third, fourth language.

And more than that, "I literally don't feel safe. I'm worried that people here hate me or wish me harm purely because of who and what I am." And once you introduce intersectionality into that, you get into some real difficult situations where suddenly it's not just, “I'm worried because of the color of my skin or because of the way I sound”, but it's because of just “the person I have at home, because of where I came from”. And, again, this culture of tribalism, if we flip it on its head, if we stop being like everything is terrible, we are starting to understand the power of a diverse and inclusive team.

Dr Sridevi: I think on that note I guess what we're getting at here really is also the idea that there's a certain way that's superior, right? This over here is what it should be like. And this is superior. Anything different is inferior. So that's the crux of it.

And, of course, we understand from the evidence that it's exactly the opposite. That diversity of thought, of person, of culture is hugely beneficial to teams, to corporate bottom lines, to the quality of care we can give because we understand the diversity of our patients better, so we are able to respond in a much more person-centered way, not just to, you know, this is-this is where I'm from and I'm seeing this through my lens because our lens then is multifaceted. And we can see people through all of these different aspects, which empowers us, that is health givers, to be able to give that really nuanced, improved care. And it improves the outcomes. We know that.

So I absolutely agree that it is about how we frame diversity and difference and, you know, whether we value it or not. And a lot of that can come from what our seniors think about and what they role model and I think we are also products of our society. And right now, there's a lot going on in society that isn't particularly helpful, actually. I think there's a lot that is, and we're almost at this crossroads, I think, and we're just about to go over and into that right direction but we're not quite there yet. And there are quite a few people we need to take with us as well, but we will get there.

Dr Sweeney: Definitely. So there-there was something that Simon said about how even just witnessing, somebody experiencing discrimination can have a profound impact on somebody's productivity and the way that they treat patients. And it sounds from this narrative that the trainee felt really isolated and alone. And we've spoken about allyship and things like that, and I wondered if you had any advice for trainees who might witness this kind of behavior in the workforce.

Simon: Yes. So, being a bystander is really difficult and really uncomfortable, right? Sometimes it's a bit, you know, mommy and daddy are arguing. And sometimes it's-it's far worse because you know that it's wrong. It And you nearly get into the realms of kind of moral injury, right? You are watching something that goes against your core values, and you have a choice to make, which is, do you do something or do you not? if you don't, then you get those feelings of guilt and shame. And they can be really quite powerful and really quite uncomfortable. And as a bystander, there's all kinds of things you can do.

I think about them in terms of-of the Five “D’s” of being a bystander. So, you can be direct, right? Sometimes you just have to be. So that is whether you use verbal or non-verbal behaviors or actions to intervene. Now, sometimes it's explicit, "Excuse me. Sorry, I don't know what's going on, but that's really not okay." Sometimes you can be direct but do the kind of what we sometimes call a micro-affirmation. So you see someone shouting at someone in a corridor and you kind of interrupting, "Oh, sorry. I heard you shouting.  Do you need help? it all sounds very exciting”.

Micro-affirmations are really great as well when you-you-you witness sexism. They tend to work really well because the classic way a lot of sexist comments end is- “You know what I mean." And it's really great to go, "I honestly don't. Could you explain?" And then just enjoy the uncomfortable silence while they reflect on what they've done. You can distract. You can change the topic. You can comment on something more positive. So, again, it's that micro-affirmation thing. So you can sometimes just distract. You put in that fire break in that moment.

You can delegate. I encourage people to do this all the time because we work in such a hierarchical system that sometimes it's just not for you and you go-and you phone a friend. And whether that's an ally, whether that's a freedom to speak up guardian, whether that's just a colleague that you know is bossier and more willing to have a more explicit conversation, that you can delegate.

You can delay. You can walk away, and you can say, "I will go and find one or both of the people involved afterwards, and I will support the person who's experienced those things, make sure they're okay, but also I will go and find the person who is doing these behaviors and have that more difficult conversation. But I can't do it now. It's not the time. It's not the place. It's not for me." And then, I guess the final D, is to document.

Now, I don't necessarily mean document like a Datix, but it's always good to just make some notes. If you think it's the kind of thing where you feel like you need to intervene, having some direct quotes, having a little bit of evidence, even if it's just on your phone or something, just so you can go, "Actually, what really struck me was that they used this term." Or, you know, "The bit that made me uncomfortable and kind of played on my spider-sense was the way they positioned themselves so that the other person couldn't get out the room," for example.

So those 5Ds, tend to be a quite nice way of thinking about how to be a bystander because I think we've all experienced it. And what do you do with that? How do you approach that? But there are ways of doing it because (a), we know that if you don't do it, people tend to experience some form of-of moral injury because they hate walking past it, and (b) because, and it's really interesting, and the data, again, supported in healthcare and the wider world is, if you ask doctors as an example, whether they've experienced bullying, undermining, harassment, discrimination, you'll get between a 5% and 10% rate of, "Yes, I have experienced these things."

If you ask the same population but have you witnessed them, you'll get somewhere between a 60% to 80% rate. And that's because we don't like to think of ourselves as victims and we really don't like to think that we experienced it and just took it. We just took it. And I'm privileged enough to go around the country, and before the pandemic, the world, doing this work. And the number of people who will say, "Look, I have never experienced racism, sexism, homophobia, or bullying ever but I see it all the time." And everyone in the room says that, and you're like, "Right. The math doesn't add up."

"What about when professor so-and-so said this to you? That's sexism." "Well, it's only sexism if I think it's sexism. And I was all right with him calling me a dolly bird or slapping me on the bum or saying that some women shouldn't be surgeons and the rest shouldn't be women." You know? "Oh, it was just a joke. It was just banter." And so there's that really interesting narrative as well about if we accept that actually as a bystander you have a responsibility as well, it completely changes the way we approach these things rather than, "If it's not happening to me, it's not my problem."

And I guess it kind of ends with a kind of call to arms, and it's something that I reflected on a lot during Black Lives Matter but to be fair, it comes up a lot generally. I don't think in healthcare it is enough to not be a racist. I think if your baseline is, "I'm not a bully," I don't think you should get a medal for that. That shouldn't be our baseline, you know, because you see it when stories in particular around sexual harassment, discrimination, and violence come up, people go, "Well, I've never done that." Like, "What do you want? A pat on the back because you're not a rapist."

I think we, as members of the healthcare community, have a duty to be anti these behaviors, which is an active process. You have to be actively anti-bullying, harassment, and discrimination. It is not enough to just not do it yourself. But because it's active, it's a choice. You have to choose that these behaviors will not stand and that if you see them, you will do something about them.

Dr Sweeney: Thanks, Simon. So it's not just about not being a bully, it's about actively doing something about it if you witness it. You mentioned about sexual harassment, and that sort of brings us onto our final narrative, um, which I'll go ahead and read out.

"I was a junior doctor working in a community psychiatric post. Two months into my placement, I raised concerns with my TPD about how my clinical supervisor's behavior was making me feel. They asked intrusive questions about my personal life, including my sexual experiences as a teenager. This was both alone and in front of colleagues. And asking questions about my current relationship, using derogatory language to describe my family situation. They all also commented on my appearance, suggesting things I might try such as wearing my hair down."

"They did this to other members of staff too and were well known by other members of the MDT as being flirty. I dreaded coming to work and avoided one-to-ones as much as possible. I raised concerns with my TPD who escalated them, leading to my prompt relocation and a formal investigation. Other trainees have mentioned having similar experiences with this supervisor before but never addressed them."     Sridevi, could I come to you first for comments on this?

Dr Sridevi: Yeah. So in that situation where effectively there's, you know, sexual harassment, it's interesting that others had noticed it again and they hadn't said anything. So, it is this kind of culture and fear that surrounds the ability to raise issues. And it's really good to hear in this situation that very swift action took place. It was dealt with. Of course, we don't know what happened with the trainer, but I'm hoping that they were able to, you know, receive some support to reflect on what's happening and to change their behavior, as well as also, you know, obviously dealing with it through, if necessary, more formal routes.

So, it's good that it ended in this way in this particular situation, but we know obviously, for the previous trainees, it didn't because they didn't raise it. And also, we know that lots of people are experiencing this, you know, around the country and it doesn't get raised. And what can we do to improve that? I think it is important for people to understand who they can raise it with, you know, within their training directorate, even getting together with a group of their peers and checking in, you know, have others experienced it. And maybe going as a group can also be helpful. It gives a level of kind of confidence and protection should people feel they need it.

Dr Sweeney: Simon, from a sort of trainee's perspective, what are your thoughts?

Simon: I mean, this is a really common story, unfortunately. These behaviors, in particular sexual harassment and sexual assault are actually pretty common in training more so than I think a lot of us would-would like to admit. I mean, if we really drill down into it, you know, the behaviors we are talking about is often written off as locker room talk and banter and all of these words that really cover a broad range of behavior from-from unintentionally creating a-a hostile, toxic, and unsafe environment to unwanted physical contact in some way.

And I think the problem is that the milder end of this spectrum we often underestimate it, underplay it, and write it off. It's everyday sexism, it's everyday sexual harassment, right? "Oh, but it was just a compliment that I said that your bum looked good in your dress today." Or "Well, she smiled and laughed." And it's so easy to write it off because it's done in either jovial way or they're perceived by some to be positive remarks, but they still objectify. They're still not acceptable.

And, again, the data around sexual harassment is very much the same as the data around bullying in terms of the reasons why people don't report it. You know, I'm more au fait with the data from surgery, but there are pretty significantly reported rates of harassment up to and including sexual assault and rape in surgical training. And we don't have that data for the UK but we have it for the United States and for Australia and for a couple of other European countries.

And I guess the challenge we have is, again, having those conversations which go, "In the workplace, these behaviors are simply unacceptable, and in the workplace, these behaviors are not acceptable, and we need to have a conversation about it." And one of the-one of the models I use for these conversations is the Vanderbilt cup of coffee model, which I don't know if you know it's data-based in that they looked at tens of thousands of conversations around workplace behaviors. And basically, what they said is the vast majority of people don't need any of these conversations. They just carry on with their days.

But, um, say, you have a single unprofessional incident. So, say, you drop something, and I say, "Oh, Dr Sweeney," while you're down there, and I raise my eyebrows in a disgusting, creepy, and suggestive manner, you might feel comfortable having a conversation with me. Otherwise, again, you can delegate, where we go for what's called a cup of coffee conversation. You carry on with your day and you go, "Simon, can we just go for a chat?" And we go somewhere that's not your place of power, not your office or whatever, not my place of power, not my office.

It's not a corridor. It's not in front of everyone. We go for a cup of coffee. And, this intervention you feedback to me about how that might have made you feel, You know, that whole thing about like what's it being on the receiving end of that comment, et cetera, et cetera, et cetera. And the evidence all suggests that over 95% of people will change their behavior on the basis of that conversation. I might not like it. I might get defensive. I might say, "Woke millennials got no sense of humor nowadays," but I'll still change my behavior.

Now, say, there's an apparent pattern. Say, that you notice that I make jokes or comments like that every day. I’m, what was the-the narrative? I'm flirty as well in a way that maybe doesn't make you feel comfortable or probably isn't appropriate. So that's when you have an awareness intervention. So no cup of coffee. Now we have a meeting and there's an email chain and maybe there are some minutes taken.

You know, you say, "Look, I really do need to have a conversation with you." And you send me an email saying we need to talk about this again. And, say, I still don't stop. So, we've had a cup of coffee chat and we've had an awareness intervention in an office somewhere. So, then you have what's called a guided intervention by authority. In other words, it's not you anymore, unless you're very important. It is, say the medical director or the clinical director or, someone very senior from HR.

And they sit me down and they go, "Look, Mr. Fleming, we've heard about your banter, your locker room chat, and we know that you've had a cup of coffee conversation and a kind of an awareness intervention, but now we are saying that you need to stop these behaviors because they breach the following laws, guidelines, protocols, but can we help you? Can we support you? Do you need to go on an equality and diversity course or whatever? But let us be very clear this is the standard." And then if I continue these behaviors, the final-- the tip of that pyramid, the final point of accountability, that's your referral to the GMC.

And the reason why this system works is, number one, it's evidence based. Number two, it demonstrates there's an escalation policy. Number three, their protocol recognizes that some behaviors are so unacceptable that you skip certain steps. You know? So if I grab your bum in a hallway, I don't get a cup of coffee conversation, right? You go straight to that guided intervention by authority, probably. In fact, it would even be arguable that you should go straight to disciplinary action, right? And it works. But also, and this is the point, it comes back full circle to where we started, which is do the best you can until you know better, but once you know better, do better.

And I'm not saying that a lot of people don't know better, but often, and I've had a lot of these conversations with people, no one has explicitly said, "Are you aware that when you make that joke, tell that story, do that thing, it's not okay?" And a lot of the time, they go, "No." And these kinds of sexual harassment episodes, we're very lucky in the UK, we haven't had a central event like Australia have, like America have, but we need to accept that all of these little flirtations and little jokes that people write off are not that little.

And actually, we have a duty to challenge them. But we can do it in a way that allows the person to change unless those behaviors are such that they mandate real and immediate accountability because we let stuff slide that the rest of the world would be horrified with. And it's because in healthcare we think we're special. And we're really not. The same societal rules apply. So now we know better, we just have to do better.

Dr Sweeney: Yeah. I really like the way you talk about having, you know, if it's a single unprofessional incident, you have that sort of cup of coffee conversation and escalate it. And what really comes through is the kind of trying to understand where that behavior is coming from, rather than just pinning blame and labeling somebody, "You are a bully." Is that trying to understand. But, obviously, there are some behaviors, like you said, that are just categorically unacceptable and need immediately dealing with. Sridevi, do you have any other comments?

Dr Sridevi: I suppose reflecting, you know, around about, you know, bullying and harassment, we work in such highly pressured situations often in health care and it is thinking about how do staff across the board get the right support, which means that they can turn up to work and do a good job, rather than be under so much stress that behaviors that are not even how they would normally behave start to become apparent. It's almost a kind of a stress response. It's a, you know, letting out steam in a different way because actually, they're not able to in the normal, way of working because of the way things are in our system.

So, I think that whole issue of workforce wellbeing, where is that? How are we making sure that's properly embedded is really essential because by looking after people, I think that really allows and supporting them to understand how to look after themselves; it supports that ability then to turn up in a more compassionate way and to not take out the issues that they haven't been able to deal with, and the pressures they haven't been able to deal with, to be taking that out on their fellow members of-of staff.

And for people who still need to see the evidence and the proof, I mean, We've just called beyond that. And I think things like the work that you're doing here, the Royal College of Psychiatrists, I'm really proud of them for taking the anti-racist stance, for talking about and explicitly modeling what inclusive, compassionate leadership looks like. And that, of course, does not include bullying and harassment.

Dr Sweeney: Absolutely. And I think having these conversations and discussions is so important. Thank you both for joining me today. And thank you for listening to this PTC podcast on bullying and harassment. We hope you found it useful. If you've been affected by the issues raised in this podcast, or if you would like further information, there are a number of resources linked to this podcast on the Royal College website.