INTIMIDATING BEHAVIOUR TOWARDS MEDICAL STUDENTS IN THE CLINICAL

ENVIRONMENT
Report and Recommendations from an Otago Medical School Workshop held in
Dunedin on 15/12/15

1. Introduction
A workshop was organised after an approach to the Otago Medical School (OMS) by student representatives
about the issue of bullying in medical education. The aims of the workshop were to generate cohesive policy and
process around the issue, and for the Otago Medical School to articulate an agreed stance, given recent publicity.
The number of attendees at the workshop was deliberately restricted. The initial draft report was circulated
widely for comment. A small group then met and amended the original report to reflect the consultation
responses. This final agreed document is now presented for approval of the recommendations.

The report and its recommendations are intended to clarify the stance of the Otago Medical School in relation
to bullying behaviour towards students, and support students with an effective informal process that gathers
information, protects students from prejudice because of reporting, and is in addition to formal processes within
the University and DHBs, which are the pathways to laying formal complaints. Particularly, the processes
outlined are in addition to, and not in replacement of, the Ethical Behaviour Policy of the University of Otago.

The Ethical Behaviour Policy sets out University wide informal and formal processes. Appendix 2 in the Ethical
Behaviour Policy document describes available informal processes, including the work of the University Mediator
and the availability of the Ethical Behaviour Network, who are a group of Otago staff and students who are
trained to provide a first point of contact for anyone who has concerns. The members of the contact network
wont tell a student what to do but they will provide a safe place to talk through concerns and identify options.

Contact Network in Wellington Contact Network in Christchurch

Contact Network in Dunedin Contact Network in Southland

2. Attendees
Attendees present at the original workshop were:
Professor Peter Crampton, Dean Otago Medical School (Facilitator)
Dr John Adams, Associate Dean Student Affairs, OMS
Dr Lynley Anderson, Senior Lecturer, Bioethics Centre
Ms Lauren Barnett, Trainee Intern MB ChB, DSM
Ms Malia Begley, Trainee Intern MB ChB, DSM
Mr Kieran Bunn, 4th Year MB ChB, UOW (attended by teleconference)
Ms Emily Dwight, 4th Year MB ChB, UOW
Mr Mike Fleete, Trainee Intern MB ChB, UOW (attended by teleconference)
Dr Ben Gray, Senior Lecturer, Primary Health Care & General Practice, UOW
Associate Professor Jan McKenzie, Associate Dean Student Affairs, UOC
Dr MaryLeigh Moore, Senior Lecturer & Simulation Centre Director, UOC
Ms Kim Noah, 4th Year MB ChB, UOC
Dr Kelby Smith-Han, Teaching Fellow, OMS
Mrs Lyn Smith, 4th & 5th year and MEG Administrator, DSM
Ms Maddy Tagg, Trainee Intern MB ChB, UOC
Ms Ann Thornton, Student Affairs Administrator, UOW
Mrs Jillian Tourelle, Manager Student Affairs, OMS
Professor Tim Wilkinson, Director MB ChB Programme, OMS
Dr Sue Walthert, Associate Convenor Professional Development, DSM
Apologies:
Dr Joanna MacDonald, Associate Dean Student Affairs, UOW (due to illness)
Dr Hamish Wilson, Early Learning in Medicine, OMS

1
3. Summary of Recommendations
The meeting reiterated the Otago Medical Schools position that safe and supportive learning environments are
the cornerstones of quality learning, and that intimidating or abusive behaviour towards students has no place
in modern medical education.

a) Safe pathways for reporting:

Policy
1. Reports about intimidating behaviour in the teaching environment should be encouraged
and will be collated and retained in one place. Students and others can report through a
number of channels.

Procedures
1. The various pathways should be made known to all staff and students.
2. An incident reporting form should be created and made generally available.
3. Students should be surveyed regularly and asked for feedback on both meritorious and
intimidating teacher behaviour.
4. Reports from multiple sources (see fig 1) will be passed to the Associate Dean of Student
Affairs in the relevant School, who will be responsible for collating, recording and retaining
reports.
5. The processes through which such information is handled and interpreted should be made
explicit to staff and students.

b) Processes and procedures once reported:

Policy
1. Reports of serious or egregious intimidating behaviour will be passed immediately to the
relevant Dean, who will take action as appropriate in consultation with HR, under the relevant
policies, guidelines, and terms and conditions of employment of the staff member.
2. All other reports of intimidating behaviour (confidential but not anonymous) will be considered
by an assessment group at each campus, chaired by an independent person, and further
actions taken if, or when, an appropriate threshold has been reached.

Procedures
1. The relevant Dean will investigate reports of serious instances, and will involve the student, the
HoD, HR, the Proctor or the DHB as necessary. Formal disciplinary action may need to be
taken.
2. An independent Chair will convene a Behaviour Assessment Team to consider all other new
and existing reports as needed.
3. The Chair will feedback to the person(s) reporting what action the team proposes to take.
4. If the team decides that the appropriate threshold has been reached, and the person reporting
is in agreement, this information will be passed to the relevant Dean, who together with the
appropriate HoD or DHB management, may discuss the issue with the staff member
concerned.
5. Campuses will ensure that information about sources of support for those reporting are
communicated clearly (e.g. on Moodle), and that students reporting receive appropriate
guidance and support from Student Affairs.

c) How to change Cultures:

Policy
1. The Otago Medical School will support intervention and research initiatives in governance and
operational areas that have the potential to improve the quality of learning environments.
2. The Otago Medical School will initiate and support education for current teachers and students
on constructive teaching methods.

2
 d) Increasing student resilience in the working environment:
Policy
1. ALM Campus Schools will provide programmes that support and up skill students in learning
and dealing with challenges in the clinical environment.

Procedure
1. MCC will evaluate initiatives in the area introduced in Schools and determine what could be
implemented in a consistent manner across ALM Campus Schools.

4. Safe pathways for reporting

a) Intimidating behaviour:
The Otago Medical Schools position is that safe and supportive learning environments are the cornerstones
of quality learning, and that intimidating or abusive behaviour towards students has no place in modern
medical education.

This begs the question about what constitutes such behaviour in the teaching context. The Universitys
Ethical Behaviour Policy says:

(e) Unethical behaviour includes, but is not limited to, sexual harassment, racial harassment,
discrimination, personal harassment and bullying, the abuse of supervisory authority and failing to
declare or manage a conflict of interest.

The MCNZs Statement: Unprofessional behaviour and the health care team. Protecting patient safety
says:

Such behaviours include but are not limited to:

bullying or intimidation
sexual harassment
racial, ethnic or sexist slurs
loud, rude comments
intimidation, abusive or offensive language
persistent lateness in responding to work calls
throwing instruments
offensive sarcasm
threats of violence, retribution or vexatious litigation
demands for special treatment
passive aggression
unwillingness to discuss issues with dependent colleagues in a cordial and respectful manner;
including handover meetings.

In a teaching situation this includes behaviour that is aimed at humiliating students, particularly in front of
others, for any reason, including the limits of their knowledge or competence.

Students accept that teachers questioning them to the boundaries of their knowledge, as in the Socratic
method, is often a valuable learning exercise. However, the teachers behaviour once that boundary is
reached, is crucial. Belittling or criticising the student at this point is not acceptable. Medical students, as
senior University scholars, should expect to have their work and understanding challenged, but this has to
be done in a way that leads to constructive learning.

3
b) Reporting Intimidating Behaviour:
The Otago Medical School fully endorses the absolute need for a system where instances of intimidating
behaviour can be reported easily, with the student feeling supported and validated in their concerns. The
Otago Medical School will also continue efforts to ensure that reporting intimidating behaviour has no
impact on a students progress.

A student might first be able to confer with peers or other colleagues about the incident. Sometimes,
additional perspective is gained in this way from others knowledge and understanding. Reporting is
available through multiple differing channels. Within ELM, a student can approach their OUMSA
representatives, their lecturers, tutors, convenors, administrative staff, Student Affairs or the ELM Director.
In ALM a student can talk with their student representatives, the convenor of the attachment, the HoD,
Student Affairs, the Dean, their mentor, or write about it in a TPER (Thought Provoking Episode Reports).

It is considered that a new form for providing reports of incidents should be made available. Students should
regularly be asked for feedback and comment on any incidents of concern. The Otago Medical School
therefore endorses the idea of regular (perhaps at least twice yearly) requests of students to provide any
feedback about both meritorious and intimidating teacher behaviour.

There are, however, clear, and understandable, barriers to reporting:

1. The behaviour may not have reached a threshold where action is warranted yet unless
multiple sub-threshold incidents are recorded, patterns cannot be detected or acted upon.
2. Multiple pathways to reporting may make it easier to report but may also make it harder to know
which pathway to use
3. Students feel hesitant about reporting poor behaviour because of a fear about potential impacts
on their academic progress, or because they lack confidence to know if it is serious enough.
Sometimes students do not want to make a formal complaint, but want someone to know about
intimidating behaviour, and have their feelings validated.
4. The distinctions between anonymous reporting and confidential reporting are not necessarily
widely understood.
5. There can be a misplaced expectation that observing (or reporting) a behaviour must also be
accompanied by a judgment or interpretation of that behaviour, and that such judgements must
be made by the observer. However the observer may not be in a position to interpret or judge.
This means there needs to be a separation between data collection (observation and reporting)
and interpretation and judgement.

Reporting should be seen as being more usual much as the clinical culture has moved to seeing quality
and safety incident reports as being normalised methods to help raise standards of clinical care.

Bystanders (other clinical and general staff, and other students) have a critical role to play, and should also
be encouraged to report instances where in their view, behaviour towards students was not satisfactory.
Bystanders could choose any of the above portals for input. An incident form may also be of particular
use for bystanders.

Unless reported behaviour of a single incident is particularly egregious, better data would come from
keeping multiple reports and observations over time. In this way patterns of behaviour with individual
people or services could be determined and acted on as needed.

Multiple pathways for reporting should lead to one final common pathway. The Associate Dean of Student
Affairs (ADSA) should be responsible for collating and holding the information and presenting that
information for review.

That review should take place by a well-informed group at each campus chaired by an independent person
outside the Medical School and DHB.

4
Recommendations:

Policy
1. Reports about intimidating behaviour in the teaching environment should be encouraged and
will be collated and retained in one place. Students and others can report through a number of
channels.

Procedures
1. The various pathways should be made known to all staff and students.
2. An incident reporting form should be created and made generally available.
3. Students should be surveyed regularly and asked for feedback on both meritorious and
intimidating teacher behaviour.
4. Reports from multiple sources (see Figure 1) will be passed to the Associate Dean of Student
Affairs in the relevant campus, who will be responsible for collating, recording and retaining
reports.
5. The processes through which such information is handled and interpreted should be made
explicit to staff and students.

General Staff

ADSAs

Convenors

PD Convenors ADSAs

Student Leaders

Deans

Solicited Comments

Critical Incident reports

Figure 1

5
5. Processes and procedures once reported
Closing the loop with information received through the reporting process presents some interesting issues.

If the student (or other) wants to pursue a formal complaint, the matter can be passed from the ADSA to
the Dean for investigation and further action, or, if University staff or other students are involved, the
student can write directly to the Proctor. Formal complaints, through the requirements of natural justice,
will mean that the identity of the student and what they are saying will be made available to the person
about whom the complaint is made. Such a process is likely to be initiated for incidents which are clearly
beyond an acceptable threshold.

Students often do not want to be identified, and sometimes do not feel that the situation is of such severity
that it warrants a formal complaint. What is frequently wanted is some feedback to the perpetrator, or
collation with other information, about their behaviour. One low level complaint may mean little about
the persons usual behaviour. A series of complaints may begin to establish a pattern that has more
substance.

The Otago Medical School is of the view that information collected over time that establishes a possible
pattern in someones behaviour, should be fed back to them. Depending on the nature of the pattern of
behaviours, this could be done in an informal way, probably by the Dean or HoD. e.g. Several reports of
instances of you saying things that might be construed as racial slurs have come to our attention and we
thought that you should know that this is a perception of you that is building. However, some issues may
need formal reporting mechanisms.

This raises the issue of assessing the information from the multiple sources and making a decision about
whether this reaches a threshold that indicates that it should be passed to the School Dean, or HoD of the
relevant Department for action. While the ADSAs hold the information, such decisions are best made by a
group. In order for students to trust the process and believe that their reports will be taken seriously and
not impact on their progress, that group should be chaired by an independent person at each campus. The
Otago Medical School therefore proposes the establishment of a group (Behaviour Assessment Team),
chaired by someone independent, meeting as needed, that would review new information that comes to
hand, assess it against any existing information, and make the decision as to whether the threshold has been
reached to pass the information on for informal action. (Figure 2) The group would also consider the best
person or persons to pass the information on to.

The Chair of the group should feedback to the person(s) who have initiated the report what action is
recommended, before taking such actions. This leaves the person in charge of the process, and closes the
loop.

Support for the reporting person needs to be explicit and available. Student Affairs would normally take the
lead role in ensuring that any student reporting intimidating behaviour has the required support in place.
Sources of support should be well communicated to students.

Reporting students also need to be made aware that should formal disciplinary action be taken in the future
outside this informal process, any documentation is likely to be discoverable.

Recommendations:

Policy:
1. Reports of serious or egregious intimidating behaviour will be passed immediately to the
relevant Dean, who will take action as appropriate in consultation with HR, under the relevant policies,
guidelines, and terms and conditions of employment of the staff member.

6
2. All other reports of intimidating behaviour (confidential but not anonymous) will be
considered by an assessment group at each campus, chaired by an independent person, and
further actions taken if, or when, an appropriate threshold has been reached.

Procedures:
1. The relevant Dean will investigate reports of serious instances, and will involve the student,
the HoD, HR, the Proctor or the DHB as necessary. Formal disciplinary action may need to be
taken.
2. An independent Chair will convene a Behaviour Assessment Team to consider all other new and
existing reports as needed.
3. The Chair will feedback to the person(s) reporting what action the team proposes to take.
4. If the team decides that the appropriate threshold has been reached, and the person reporting is in
agreement, this information will be passed to the relevant Dean, who together with the appropriate
HoD or DHB management, may discuss the issue with the staff member concerned.
5. Campuses will ensure that information about sources of support for those reporting are communicated
clearly on (e.g. on Moodle), and that students reporting receive appropriate guidance and support
from Student Affairs.

General Staff

Behaviour Assessment Team (Independent Chair)

ADSAs

Convenors

PD Convenors ADSAs Dean

Student Leaders

HoDs

Deans

Solicited Comments

Critical Incident reports

Figure 2

7
6. How to change Cultures
Dealing with individuals is only a part of dealing with the issue of intimidating behaviour in the medical
learning environment. Poor behaviour towards students is not limited to medicine as a profession, nor to
doctors as individuals. Medical students can be on the end of intimidating or uncivil behaviour from other
health professionals, managers, and administrative staff. Often such behaviour is tolerated by, or even
encouraged by, the prevailing work culture. There is a significant task to change the way that things are
done.

Furthermore, there is a need to shift the bell shaped curve not just detect the bad apples. Identifying and
celebrating meritorious behaviour, and encouraging bystanders speaking up are just some of the ways to
do this.

The University is only a part player in any attempt to make things different. The environment and attitudes
in both DHBs and Primary Care contribute majorly to the nature of learning environments.

An example of a move in this area is the recent initiative from RACS (Royal Australasian College of Surgeons),
which has sent a powerful message about standards of expected behaviour not only to surgeons, but also
to the public. Patients are deeply involved in this whole issue as one outcome of intimidating or uncivil
behaviour is poor patient care.

Dr Lynley Anderson, Professor Tim Wilkinson, Dr Althea Blakey and Dr Kelby Smith-Han have initiated a
research intervention project aimed at positively changing the quality of learning environments. This project
grew out of an idea to establish a code of conduct for teachers. It was thought that generating aspirational
goals for learning environments, rather than focusing on individuals, and rewarding those that were
achieving the goals would have greater impact. The project will be a joint project with Auckland Medical
School, and will begin with an intervention in the Southern DHB. A brief description of this project is attached
as appendix 1.

The Otago Medical School supports working with DHBs to change culture.

There are potential high level governance interventions with the DHB that could be pursued through the
MoU process and the Joint Relations Committees, to set expectations about teaching and behaviour towards
students. For instance, many years ago there was an initiative in Dunedin to have joint job appraisals for
both University and DHB staff. This would mean that teaching performance could be a part of the appraisal
for DHB staff. Currently, there is no formal mechanism for feedback on teaching performance for these staff.
MoUs could specify aspirational goals for learning environments and that information on unprofessional
behaviour should be shared between organisations.

Efforts to provide training and education sessions for staff across the University, DHBs and Primary Care on
teaching methods, providing feedback and what makes a good learning environment should be
strengthened. Consciousness should be raised about what is OK in teaching and what is not. The aim is to
have learning environments that staff feel proud of belonging to.

Learning about teaching starts in Medical School. Greater efforts could be made to teach students about
how to teach, so that the next generation of medical teachers is up skilled.

Students comment that they fear that teachers would pull back or pull out if they began to worry that there
would be reprisals for their manner of teaching, and if they were unsure of what was acceptable.

Recommendations:

Policy
1. The Otago Medical School will support intervention and research initiatives in governance and
operational areas that have the potential to improve the quality of learning environments.

2. The Otago Medical School will initiate and support education for current teachers and students on
constructive teaching methods.

8
7. Increasing student resilience in the working environment:
The meeting acknowledged that by its nature, the clinical environment can be challenging. Expectations of
quality and excellence, as well as peer and colleague review are a usual part of ongoing quality assurance
and improvement. Furthermore, stressful environments can create tensions that need to be recognised and
handled in order to promote optimal clinical care.

Students at the meeting commented that some introduction to teaching methods, such as Socratic
questioning, that are used (appropriately) in the clinical environment could be provided in ELM, so that
students are prepared to be challenged and do not construe such methods as personal attacks. A little
discomfort stimulates learning. Methods by which health professionals learn in workplaces can also have
applicability to medical students.

Students also said that a transparent discussion at the beginnings of attachments about how they would be
taught and the use of interrogation to find thresholds of knowledge would prepare them and leave all
parties feeling valued. This is the way that we do things here to increase your knowledge..

The meeting supported the idea of interventions aimed at giving students skills to deal with challenging
situations in the work environment.

Dr Sue Walthert (DSM PD Convenor) has with a DSM working group, developed a strand programme in the
Professional Development vertical module, Real Life Relationships, Learning to work together in complex
work environments . This programme represents an educational response to the issues of intimidating
behaviours at medical school. The development of the programme was supported by DSM. A final proposal
is in the process of being assessed. It contains learning opportunities in three arenas: lectures and seminars
on cognitive knowledge about working together in complex work environments; new ACYST groups on
relational challenges that will replace and upgrade mentoring groups; and initiatives in the institutional or
environmental arena. ACYST stands for ALM Clinical Year Support Training groups. ACYST groups will provide
students with regular opportunities to review their learning experiences, cognitive rehearsal of different
ways of relating with others, and will also have an objective to develop understanding of doctor/patient
relationships. Such a change will require curricula time and an increase in the PD budget enabling ACYST
Fellows to be suitably up skilled and supported The proposal is currently being considered by the Dean,
Professor Barry Taylor. If implemented and successful, the key elements of this proposal should be made
known to other ALM sites in order to adapt and implement similar initiatives.

Recommendations:

Policy
1. ALM Campus Schools will provide programmes that support and up skill students in learning and
dealing with challenges in the clinical environment.

Procedure
1. MCC will evaluate initiatives in the area introduced in Schools and determine what could be
implemented in a consistent manner across ALM Campus Schools.

9
 Appendix 1

CAPLE PILOT STUDY

Creating a Positive Learning Environment

The CAPLE project aims to work with clinical staff to improve the atmosphere and
workplace environments to make them even more conducive to learning for all health
students in clinical practice.
The project is being undertaken by staff at the University of Otago, School of Medicine,
and the Otago Polytechnic, (Appendix 1) with the support of other researchers at the
University of Auckland, School of Medicine. Health professional students commonly
describe mixed experiences in their interactions with staff within busy clinical areas. These
experiences both positive and negative are described within the literature by students
both internationally and nationally. Recent media reports from the NZMSA and the Royal
Australasian College of Surgeons attest to the fact that not all students fare well during
their training. The toll on students can be significant, from doubts about career choice,
failure to learn, stress and mental health issues, and fostering persistent negative
behaviours to the next generation of students. The CAPLE researchers have a primary
focus on improving the learning environment for all health students.
A positive learning environment
Our focus is on cultivating a positive learning environment that welcomes students,
clarifies their role, encourages collaboration, and provides constructive feedback to
achieve the best learning space for tomorrows health workforce. Unfortunately a small
number of students may encounter the other end of the spectrum, where negative
behaviour may inhibit their learning. Such negative experiences might include bullying.
Our plan is not to focus on negative behaviours but to enhance and enable staff to be
highly skilled practitioners in health education, and for students to flourish within the
positive end of the spectrum.
Prior research that supports the current pilot study
To test the efficacy of our intervention, we need to gather data regarding current
student experience across the medical and nursing school, and staff buy in and
assistance.
Literature review 1
This review involved a systematic review of the literature about the prevalence and
incidence of negative behaviours in clinical practice.
Literature review 2
Literature review 2, involved a systematic review of the literature about the success or
otherwise of interventions used to combat negative behaviours. This review

10
emphasised that a positive and collaborative focus has the potential to achieve
behaviour change. Information from this review informs the content and process of the
pilot workshops.
Project summary
The proposed CAPLE pilot project is a mixed methods project using both survey
and action research methods as described:
1. We will gather baseline data about current nursing (Otago Polytechnic) and medical student
(University of Otago) experience using the NAQ-R and DREEM climate surveys. These
surveys will be repeated regularly.
2. An Exemplar survey will provide local data on educational best practice as experienced
by 5th year medical students, & 3rd year nursing students. Focus groups with staff from
highly rated departments will identify examples of good practice that will inform the
intervention.
3. The action research pilot intervention will involve a mix of 12 doctors and nurses from a
DHB department. These participants will be allocated a named researcher, with whom they
will foster a relationship of trust, in order to generate ideas for interventions that are
feasible, and applicable in a wide variety of clinical workplace settings. We anticipate
workshops may well form part of the intervention so we will suggest 4-5 workshops from
which participants can choose. Workshops will be open to all staff from the area.
4. An atmosphere survey (pre and post pilot) of clinical staff will detail changes over time for
the duration ofthe pilot (12 weeks).
The success or otherwise of the action research pilot intervention will be determined by the
analysis of the
atmosphere survey of staff and qualitative data collected about the intervention
through transcribed interviews, emails from participants and reflective journals kept
by participants.

Funding for this project has been provided by the Pro Vice Chancellor, Division of
Health Sciences, University of Otago. Our focus is on cultivating a positive
environment. This focus is supported by the international literature.

APPENDIX 1 CAPLE Team members and experience

Prof Tim Wilkinson: Director, MB ChB programme (Faculty of Medicine), Deputy
Dean (Christchurch). Geriatrician.
Associate Professor Lynley Anderson: Bioethics/Professional Development Convenor Early
Learning in
Medicine, Bioethics Centre, University of Otago. Previous experience as a physiotherapist.
Dr Kelby Smith-Han: Post-Doctoral Fellow, Medical Education, Anatomy Department,
University of Otago. Previous experience as a psychologist.
Dr Althea Blakey: Post-Doctoral Fellow, Medical Education, Bioethics Centre, University of
Otago. Previous experience as a radiation therapist.
Emma Collins: Senior Lecturer, School of Nursing, Otago Polytechnic. Current paediatric
Nurse
Liz Berryman: 5th Year medical student, University of Otago. Previous experience as a nurse.

11
 APPENDIX 2 - Definitions Bullying can mean unwanted and unwarranted behaviour that a
person finds offensive, intimidating or humiliating and can be repeated so as to have a
detrimental effect on a persons dignity, safety and wellbeing. Examples of bullying can
include:
Physical (push, shove, hit)
Verbal (called names, humiliated, insulted)
Social (excluded, gossiped about, rumours spread, professionalism undermined)
Racial (heard or received racist remarks)
Sexual orientation/Gender identity (heard or received negative remarks about
sexual orientation or gender identity
Gender (heard or received sexist remarks)
Professional (e.g. failure to sufficiently prepare a staff member for a procedure,
failure to listen to opinion, unreasonable requests).

12