Acting out problems in the workplace
Sydney University has taken a creative approach to the issue of bullying and harassment. It uses theatre, as well as workshops featuring role-play by actors, to focus clinicians and students on the need for workplace culture reform.
In 2015, several young Australian doctors committed suicide. This clearly sounded the alarm about systemic problems in the way interns and junior doctors were being treated. At the University of Sydney, we already knew something was seriously wrong with the medical workplace culture; we knew we needed to highlight the problem and start a conversation about how to address it.
Also in 2015, one of our team, Karen Scott, was lead author of a paper published in the Australian Medical Journal: “Teaching by humiliation and mistreatment of medical students in clinical rotations: a pilot study”. The paper reported the results of a survey of final-stage students from two Australian medical schools about their experiences of teaching by humiliation during their clinical rotations in Semester Two of 2013.
As many as 74 per cent of the students who completed the survey reported experiencing teaching by humiliation during rounds when on adult clinical placements, and 83 per cent said they had witnessed it. The humiliating and intimidating behaviours students experienced were generally more subtle than overt, and included aggressive and abusive questioning techniques. The students’ responses to these practices included disgust and regret about entering the medical profession.
“The humiliating and intimidating behaviours students experienced were generally more subtle than overt, and included aggressive and abusive questioning techniques.”
The study called for these behaviours to be eradicated, given the evidence of negative effect on students’ learning and mental health, and the dissonance with formal professionalism curricula. “Interventions are needed to interrupt the transgenerational legacy and culture in which teaching by humiliation is perpetuated,” it concluded.
We knew that changing this entrenched culture would require novel, creative approaches, focused particularly on the clinical environment.
In 2017, with an education innovation grant from the University of Sydney, a grant from the University of NSW Big Anxiety Festival and support from the Seymour Centre, a group called the Sydney Arts and Health Collective was formed. Together we produced a verbatim theatre production called Grace Under Pressure, written by Dr Paul Dwyer from Performance Studies and Dr David Williams from The Seymour Centre.
Verbatim theatre is a form of documentary theatre that explores themes through the words of the people at the heart of the subject. In this case the production was developed through interviews with a range of health professionals and healthcare students, to highlight the complexity of healthcare workplaces, encourage critical reflection and support long-term culture change.
Grace Under Pressure was performed to health professionals, healthcare students and the general public over seven sessions at The Seymour Centre in Sydney in 2017. In addition, we developed short, professional quality videos of key segments of the play, and teaching materials to accompany them, for subsequent workshops and presentations.
“A survey conducted after the play in a Sydney LHD indicated that the audience overwhelmingly saw the play as important because it acknowledged that bad experiences occurred in healthcare workplaces and made talking about workplace culture issues easier.”
We also presented a book-in-hand performance of the play in Lismore, for health professionals, healthcare students and the general public, and ran two workshops for students at the University Centre for Rural Health in Lismore.
In 2019, a one-hour, pared down version of the play was performed at a number of local health districts (LHDs) in urban, rural and regional NSW – funded by NSW Health and coordinated by the Pam MacLean Centre, which ran workshops with staff afterwards. Focus groups with medical students were conducted across two of these sites.
A survey conducted after the play in a Sydney LHD indicated that the audience overwhelmingly saw the play as important because it acknowledged that bad experiences occurred in healthcare workplaces and made talking about workplace culture issues easier.
A planned tour of Grace Under Pressure across regional Australia in 2020 was cancelled after the first few performances, due to COVID-19, but the tour resumed in 2021.
Triaging bad behaviour
In another intervention developed by Sydney University in 2017 (by Prof Stewart Dunn and Dr Renee Lim), a series of actor-based workshops were conducted for clinical and administrative staff at Sydney LHDs.
In one workshop scenario in an Emergency Department, involving a possible fracture and potential compartment syndrome, Professor Black (actor) was called for an opinion and was belligerent and bullying. Experienced clinicians provided feedback on the possible reasons for this behaviour and in response, the workshop was revised so that the actor adopted three different motivations for the behaviour: personal stress, bullying as an educational tool, and being a pathological bully. This allowed workshop participants to triage the reasons behind Professor Black’s behaviour and to develop appropriate responses.
“63 per cent of students said it had helped them to categorise bullying behaviour, and 41 per cent reported that triaging protected their mental health.”
These actor-based workshops were repeated for students at our medical school in 2017. In 2018, approximately one year into their internship, a total of 42 of these students responded to survey follow-up. 95 per cent of them recalled the workshop, 63 per cent said it had helped them to categorise bullying behaviour, and 41 per cent reported that triaging protected their mental health.
These results showed that gaining an insight into the causes of bullying can reduce its detrimental effects on health and well-being for many students. However, a significant number (21 per cent) did not feel more confident as a result of the workshop.
More to be done
While this work has helped to get recognition of the extent of the problem, we still need to get the health system to fully accept and act on this issue. There have been encouraging signs, such as posters appearing on hospital walls advising people where they can go for help if they are being subjected to harassment. In addition, the NSW Ministry of Health has made junior doctors’ wellbeing a priority.
Some doctors who are empathetic with their patients can treat students and junior doctors very badly. This disconnect can result from overwork, long hours, or the odd justification that “it happened to me”.
The problem will only end when the healthcare workplace culture is fully transformed. That involves developing rich and creative ways of approaching the problem.
 Comprising the three authors of this story, Dr Kimberley Ivory from Public Health, Dr Jo River from Nursing, A/Prof McNeill from Sydney Health Ethics, Dr David Williams from The Seymour Centre and Dr Paul Dwyer from Performance Studies
This story is part of a series: Turning the tide of bullying and harassment in medical education and training