Bullying and Harassment in the Health Sector

Tabled: 23 March 2016

1 Background

1.1 Defining the problem

1.1.1 Workplace bullying

Definitions vary for workplace bullying. For the purposes of this audit, workplace bullying is defined as repeated and unreasonable behaviour directed towards a worker or a group of workers that creates a risk to health and safety.

Unreasonable behaviour refers to behaviour that a reasonable person, having considered the circumstances, would see as unreasonable and includes that which victimises, humiliates, intimidates or threatens.

Examples of bullying behaviour—whether intentional or unintentional—include:

  • abusive, insulting or offensive language or comments
  • unjustified criticism or complaints
  • deliberately excluding someone from workplace activities
  • withholding information that is vital for effective work performance
  • setting unreasonable time lines or constantly changing deadlines
  • setting tasks that are unreasonably below or beyond a person's skill level
  • denying access to information, supervision, consultation or resources to the detriment of the worker
  • spreading misinformation or malicious rumours
  • changing work arrangements such as rosters and leave to deliberately inconvenience a particular worker or workers.
What is not workplace bullying

Reasonable management action taken in a reasonable way is not workplace bullying—such as the allocation of work and giving fair and reasonable feedback. A single incident of unreasonable behaviour is not on its own workplace bullying, however, it may have the potential to escalate and should not be ignored. Workplace conflict is not, on its own, workplace bullying, as not all conflicts have negative health effects. However, conflict may escalate to the point where it becomes workplace bullying.

1.1.2 Harassment

Harassment occurs when a person or a group is treated less favourably than another person or group because of a particular characteristic—such as ethnic origin, gender, age, disability or religion. Harassment includes telling insulting jokes about particular racial groups, sending explicit or sexually suggestive emails or even asking intrusive questions about someone's personal life. Unlike bullying, harassment may be a single incident and is based on a characteristic of the affected person.

1.1.3 Bullying and harassment as part of a continuum

Bullying exists on a continuum of inappropriate workplace behaviour. Evidence highlights that workplace conflict or minor inappropriate behaviours can easily escalate into behaviour that is bullying or harassment. Early intervention is needed to prevent this.

In addition, minor inappropriate or unprofessional behaviours can cause harm and distress and pose a risk to health and safety, and therefore need to be appropriately resolved. This audit focuses on the continuum of inappropriate workplace behaviour which includes bullying and harassment.

1.2 Trends in bullying and harassment

The prevalence of bullying and harassment in the health sector is not conclusively known. However, research suggests that there are high levels of perceived bullying and harassment within health sector agencies (25 per cent) and in the experience of surgeons (38.7 per cent) and nursing professionals (40 per cent). Figures 1A, 1B and 1C summarise research findings.

Figure 1A

Prevalence of workplace bullying as reported by the Victorian public health sector and the Victorian public sector


'Yes' responses—

Victorian public health sector


'Yes' responses—

Victorian public sector

per cent


per cent

Witnessed bullying or harassment at work




Personally experienced bullying at work




Source: Victorian Public Sector Commission, 2013.

Figure 1B

Prevalence of bullying and harassment reported by surgeons and trainees in Australia and New Zealand


'Yes' responses —

All surgeons


'Yes' responses —



per cent



per cent

Experienced bullying in the workplace

3 079





Experienced harassment in the workplace

3 079





Experienced sexual harassment in the workplace

3 079





Experienced bullying from surgical consultants

1 098



(a) n = sample size.

Note: Trainees are those undergoing surgical education and training. Elsewhere, this group is referred to as junior doctors, along with doctors at any stage of training.

Source: Royal Australasian College of Surgeons Prevalence Study, 2015.

Figure 1C

Prevalence of workplace bullying reported by nursing professionals


'Yes' responses —nurses


per cent

Experienced bullying in the workplace in the past 12 months

4 891


Experienced regular bullying (monthly, weekly or daily) over the past 12 months

4 891


(a) n = sample size.

Source: Monash University, Leading indicators of occupational health and safety: A report on a survey of Australian Nursing and Midwifery Federation (Victoria branch) members,2015.

1.3 Impact of bullying and harassment

Bullying and harassment has been shown to have significant negative outcomes for individuals and organisations. It can cause serious physical and psychological harm to both those experiencing it and to witnesses, including:

  • distress, anxiety, panic attacks or sleep disturbance
  • physical illness, for example muscular tension, headaches, digestive problems
  • reduced work performance
  • loss of self-esteem and feelings of isolation
  • reduced job satisfaction and commitment, with those experiencing bullying more likely to have negative views on their manager, work group and organisation, and more likely to report thinking of leaving
  • deteriorating relationships with colleagues, friends and family
  • depression
  • thoughts of suicide
  • financial impacts of time off work, medical costs, loss of job promotion opportunities and risk of permanent disability.

The impact of bullying and harassment on health service organisations and the sector are significant and include:

  • high staff turnover and associated recruitment and training costs
  • reduced productivity through low morale and motivation, negative workplace culture and higher rates of sick leave and disengagement
  • increased absenteeism
  • negative impact on patient safety outcomes
  • disruption to work and high management impact through the time involved in responding to and investigating allegations of bullying and harassment
  • difficulties in recruiting and retaining staff
  • potential for significant legal costs
  • reputational risk.

In 2010, the Productivity Commission estimated the total cost of workplace bullying alone to the Australian economy at between $6 billion and $36 billion annually.

1.4 Preventing and responding to inappropriate behaviour including bullying and harassment

The risk of inappropriate behaviour and workplace bullying, can be eliminated or minimised by taking steps to prevent it from occurring long before it becomes a risk to health and safety, and by responding quickly when it does occur. Fundamental to this is the need to create a positive workplace where everyone treats each other with respect.

Adopting a risk management approach, shown in Figure 1D, enables agencies to:

  • identify the potential for workplace bullying through data and identifying organisational risk factors
  • implement control measures to prevent, minimise and respond to these risks, such as building a positive, respectful culture with good management practices and systems of work
  • monitor and review the effectiveness of these control measures.

Figure 1D

Risk management approach to bullying and harassment

1—Identifying and understanding workplace bullying

There is a risk of workplace bullying wherever people work together. There may not be obvious signs of bullying but this does not mean that it is not occurring. The key to an effective preventative approach is the early identification of unreasonable behaviour, and the examination of any underlying organisational factors that contribute to bullying and how long it is sustained.

Identify the organisational factors that can increase the risk of bullying and harassment:

Work stressors

  • High job demands, limited job control, organisational change, role conflict and ambiguity, job insecurity, an acceptance of unreasonable workplace behaviours or lack of behavioural standards, unreasonable expectations of clients or customers

Leadership styles

  • Autocratic behaviour that is strict and directive and does not allow workers to be involved in decision-making, behaviour where little or no guidance is provided to workers or responsibilities are inappropriately and informally delegated to subordinates

Systems of work

  • Lack of resources, lack of training, poorly designed rostering, unreasonable performance measures or time frames

Work relationships

  • Poor communication, low levels of support or work group hostility

Workforce characteristics

  • Groups of workers that are more at risk of being exposed to workplace bullying including: casual workers or young workers

Consider the processes and data that can help to identify the risk of inappropriate behaviours and workplace bullying:

Employee feedback

  • Regular consultation with workers, health and safety representatives, and health and safety committees
  • Anonymous employee satisfaction surveys
  • Exit interviews when employees leave the business
  • Informal feedback from different levels of the organisation, including managers and supervisors
  • Reports and feedback from counsellors, union representatives and other supporting professional staff

Organisational data

  • The number, cost and result of workers' compensation claims
  • The number and type of complaints formally lodged
  • Information about the location of each complaint, the complainant and alleged bully
  • Information about the number of people involved in an investigation
  • The result of each complaint and any follow up actions taken
  • The cost of investigations and litigation
  • Patterns of absenteeism and long-term sick leave
  • Evidence of staff turnover either directly or indirectly due to bullying, including early retirement and resignation
  • External reviews or reports

2—Controlling the risks

The risk of workplace bullying can be eliminated or minimised by creating a positive and respectful work environment where everyone treats each other with respect. A combination of control measures aimed at both the organisational level and at individual behaviours should be considered.

Establish a positive culture and respectful relationships through:

Setting the standard of workplace behaviour

  • Developing a code of conduct or a workplace policy that emphasises the required desirable and appropriate behaviours and provides the basis to address behaviours that are unreasonable before they escalate into workplace bullying

Developing good management practices

  • Promoting positive leadership styles by providing training for managers and supervisors on communicating effectively and engaging workers in decision-making
  • Mentoring and supporting new and under-performing managers and workers
  • Facilitating teamwork and cooperation
  • Ensuring supervisors act in a timely manner to reduce unreasonable behaviour that they see or become aware of

Designing a safe system of work

  • Clearly defining jobs and providing regular feedback to and from workers about their role and responsibilities
  • Providing workers with the resources, information and training they need to carry out their tasks safely and effectively
  • Reviewing and monitoring workloads and staffing levels
  • Developing and maintaining effective communication during periods of change, including restructures or downsizing

Providing appropriate training in workplace conduct, good management practices and effective response

  • Ensuring all workers, including managers and supervisors, understand their responsibilities and have the appropriate skills to take effective action to raise issues and concerns about inappropriate behaviour including bullying and harassment and to intervene early and effectively
  • Ensuring managers and supervisors have the necessary skills to develop positive workplace cultures and relationships

Implementing effective reporting and response procedures to address inappropriate behaviour and bullying and harassment

  • Building a positive culture which builds the expectation that it is a responsibility to 'call' inappropriate behaviour
  • Ensuring line managers are equipped to respond to issues brought to them effectively
  • Taking all issues raised and complaints seriously and ensure confidentiality
  • Preventing victimisation of those who make reports
  • Ensuring consistent, effective and timely responses to reports
  • Being transparent by keeping comprehensive records and regularly providing information on the number of reports made, how they were resolved and what actions were taken

3—Monitoring and reviewing

It is not enough for an employer to just establish a safe system of work—they must also maintain the system and ensure compliance.

Once control measures have been implemented, they should be regularly monitored and reviewed as part of a continuous cycle to:

  • ensure existing controls are effective in managing the risk of workplace bullying
  • ensure any new or potential hazards and risks are identified, minimised or eliminated
  • introduce the benefit of new knowledge about bullying and harassment.

Source: Adapted from Safe Work Australia, Guide for Preventing and Responding to Workplace Bullying, 2013.

1.5 Legislation

A range of legislation creates obligations on parties to effectively manage the risk of workplace bullying and harassment:

  • The Occupational Health and Safety Act 2004 is aimed at securing the health, safety and welfare of employees and others at work and eliminating risks at the source. An employer must, so far as is reasonably practicable, provide and maintain a working environment that is safe and without risks to health. This includes identifying and eliminating, controlling or reducing risks to health and safety. An employee must also take reasonable care for his or her own health and safety, and have regard for the health and safety of others.
  • The Fair Work Act 2009 covers national workplace relations laws, National Employment Standards, protection against unfair treatment and discrimination, and grievance handling mechanisms. Under the Act, a worker who reasonably believes that he or she has been bullied at work can apply to the Fair WorkCommission for an order to stop the bullying.
  • The Crimes Act 1958 makes it a crime to use, perform or direct abusive and offensive words or acts towards or in the presence of a victim, or to act in way that could reasonably be expected to cause physical or mental harm to a victim, including self-harm.
  • The Public Administration Act 2004 articulates public sector values and the Public Sector Employment Principles.
  • The Health Services Act 1988 establishes the functions of the board of a public health service. These functions include monitoring the performance of the health service to ensure that effective and accountable risk management systems are in place and adopting a Code of Conduct for staff of the public health service.
  • The Equal Opportunity Act 2010 has provisions relating to equal opportunity and protection against discrimination, sexual harassment and victimisation. It has a strong focus on the prevention of sexual harassment.

1.6 Roles and responsibilities

Health services and Ambulance Victoria

Health services are the largest employer group in the public sector. Health service boards, which often manage more than one hospital, are responsible for steering the entity on behalf of the Minister for Health in accordance with government policy. This governance role involves strategic leadership of the organisation, monitoring performance against agreed objectives and ensuring accountability and compliance. Health service boards are responsible for the occupational health and safety of their employees.

Ambulance Victoria employs more than 3 000 employees and almost 1 000 volunteers. Its board has similar functions to that of health services and is also responsible for the occupational health and safety of its employees.

The chief executive officer of both health services and Ambulance Victoria is appointed by and reports to the board, and is responsible for the day-to-day management of their agency.

Department of Health & Human Services

The Department of Health & Human Services (DHHS) has a devolved governance model and is responsible for setting strategic priorities, implementing policy, monitoring the performance of health services and providing overall system-wide guidance and funding. Devolved governance allows health services to make local decisions to meet local needs. As manager of the Victorian health system, DHHS is responsible for making sure health service boards are maintaining a duty of care and commitment to providing all employees with a healthy and safe workplace.

Victorian Public Sector Commission

Consistent with its objective of maintaining and advocating for public sector professionalism and integrity, the role of the Victorian Public Sector Commission (VPSC) is to strengthen the efficiency, effectiveness and capability of the public sector. It is responsible for issuing and applying codes of conduct and standards, and monitoring and reporting to the public sector on compliance with these standards, including the public sector values and employment principles. To fulfil these obligations, VPSC administers the People Matter survey. Health services participate in the survey on a rotating basis—half one year and half the following year.

WorkSafe Victoria

WorkSafe Victoria is the regulator of Victoria's workplace safety system. Its role includes monitoring and enforcing compliance with the Occupational Health and Safety Act 2004 and assisting in preventing workplace injuries. It also provides information and education activities.

Australasian Royal College of Surgeons

The Australasian Royal College of Surgeons (RACS) provides surgical standards, professionalism and surgical education in Australia and New Zealand. In April 2015, RACS established an Expert Advisory Group to undertake research into the extent of discrimination, bullying and sexual harassment in the practice of surgery in Australia and New Zealand. Research undertaken included a prevalence survey, organisational survey and in-depth study into the personal experiences of bullying, harassment and discrimination.

1.7 Audit objective and scope

The objective of this audit was to determine whether public health services are effectively managing the risk of bullying and harassment in the workplace.

To achieve this objective, the audit assessed whether audited agencies:

  • understand the causes, prevalence and impact of bullying and harassment
  • implement effective controls to identify and manage the incidence of workplace bullying and harassment
  • respond effectively to and address complaints and incidents of bullying and harassment
  • monitor and assess the performance of health services in effectively reducing the drivers of bullying and harassment
  • collaborate and support sector-wide initiatives to promote positive workforce behaviour.

This audit included Ambulance Victoria and four public health services. The health services comprised two tertiary metropolitan health services, one large regional health service and one small rural health service. These were selected on the basis of information contained in the People Matter survey and stakeholder consultations.

The audit also included DHHS, WorkSafe Victoria and VPSC.

1.8 Audit method and cost

During the audit, we undertook site visits to the four audited health services and Ambulance Victoria, conducting interviews and focus groups:

  • 14 individual and group interviews with executives and senior managers
  • six focus groups involving 53 line or team managers
  • seven focus groups involving 52 clinical and support staff and paramedics
  • fourfocus groups with 21 junior doctor and paramedics.

We also reviewed audited agencies' systems and documents, including:

  • relevant internal management and information systems and processes
  • policies and procedures
  • data and surveys
  • workers' compensation claims
  • investigation material.

We conducted an online public submissions process, through which we received 82 submissions from the public regarding their experiences of bullying and harassment in the health sector. While these submissions are subjective in nature, an analysis of recurring themes indicates common reported experiences of bullying and health services' response to bullying.

We also conducted a forum with human resources directors from 14 health services, which covered issues related to definitions, response, impact and prevention.

The audit was conducted in accordance with section 15 of the Audit Act 1994 and the Australian Auditing and Assurance Standards.

Pursuant to section 20(3) of the Audit Act 1994, unless otherwise indicated, any persons named in this report are not the subject of adverse comment or opinion.

The total cost of the audit was $585 000.

1.9 Structure of the report

The report is structured as follows:

  • Part 2 examines audited agencies' culture, governance and leadership as foundations for effectively managing the risk of bullying and harassment
  • Part 3 examines audited agencies' effectiveness in minimising the risk through implementing effective preventative controls
  • Part 4 examines the effectiveness of audited agencies' complaints response mechanisms
  • Part 5 examines the role of sector-wide agencies—DHHS, WorkSafe and VPSC—in supporting the health sector's management of this risk.

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