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Abstract
Disrespectful behaviour in the healthcare environment affects clinical learning, impacts those receiving such behaviour and adversely affects patient outcomes. Mandated ‘diversity training’ has minimal impact and, if poorly done, can worsen toxic work environments. Our study aimed to develop a simulation-based active bystander training (ABT) session for medical students and to evaluate the impact of this training.
Method Sessions comprised short recap of students’ learning to date; prerecorded video vignettes; a card game and immersive simulation. Advocacy with inquiry debrief, facilitated by faculty with equality, diversity and inclusivity expertise followed each scenario. Students completed a validated questionnaire developed for this study, preintervention and postintervention.
Results Sixty-six medical students from three teaching hospitals attended seven 3-hour sessions. The average number of students attending each session was 9 (range 7–12). The questionnaire was completed with matched pairs of preintervention and postintervention scores on a Likert scale by 58 (88%) students. There were significant deficits (p<0.001) in students’ self-rated knowledge with a mean preintervention score of 38.2 (SD 5.9) out of a maximum score of 55. This compared with postintervention score of 49.1 (SD 4.8). The mean increase in total score postintervention was 11.0 (95% C.I 9.4 to 12.5; p<0.001).
Conclusion We found significant deficits in medical students’ self-rated knowledge of recognising disrespectful behaviour at work. Simulation in ABT was effective in reversing this. This is a timely study given the new responsibilities placed on doctors by the General Medical Council to act when witnessing discriminatory behaviour or harassment at work.
- medical student
- behaviour
- communication
- curriculum
- professionalism
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Harassment and bullying at work impacts negatively on patient outcomes and student learning. Active bystander training is cited as a potential solution and simulation has been proposed as a method to teach students how to be active bystanders. However, evidence for its efficacy in this setting is lacking.
WHAT THIS STUDY ADDS
Simulation-based active bystander training was effective in teaching medical students to recognise disrespectful behaviour at work and increased the likelihood of intervention by students when witnessing such behaviour.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Further research is required as findings may have implications for incorporation into medical school curriculum and wider use among NHS staff.
Introduction
The UK Equalities Act 2010 was enacted to prevent discrimination and harassment of people with protected characteristics.1 Discrimination and harassment—beyond those of gender, ethnicity, disability, religious belief and sexual orientation—have no place in medical education. Disrespectful behaviour in the healthcare environment affects clinical learning and not only impacts the person receiving such behaviour, but also adversely affects patient outcomes.2 3 More concerning is the finding suggesting such behaviours have increased during the pandemic.4
The General Medical Council (GMC) recently added a ‘Racism in the Workplace’ resource on its website, acknowledging the unacceptably high levels of racism directed towards staff in healthcare setting.5 The GMC states all doctors ‘… must tackle discrimination where it arises and encourage your colleagues to do the same. You must treat your colleagues fairly and with respect. You must not bully or harass them or unfairly discriminate against them. You should challenge the behaviour of colleagues who do not meet this standard.’ Furthermore, they are clear that doctors with extra responsibilities (such as leadership or management roles) ‘… must actively advance equality and diversity by creating or maintaining a positive working environment free from discrimination, bullying and harassment. You must make sure that your organisation’s policies on employment and equality and diversity are up to date and reflect the law.’ These expectations require doctors and students to be able to recognise harassment, bullying and discrimination as well as being in possession of the skills and abilities to be active bystanders. This places an onus on medical school curricula to facilitate students develop these.
Simulation is an effective medical education tool in the teaching of basic science and clinical knowledge, procedural skills, teamwork and communication as well as assessment at the undergraduate and graduate medical education levels.6 7 Therefore, it has been proposed as a defacto way to teach learners how to respond when witnessing disrespectful behaviour. While there is some information on efficacy and impact in the context of postgraduate medical education, no evidence exists for its inclusion in already overcrowded undergraduate medical curricula.8 9
Attempting to improve matters, many organisations have mandated compulsory ‘diversity training’. However, this has been shown to have little real impact and in fact, if done poorly, can have the opposite intended effect of worsening toxic work environments.10 To inform our own curriculum developments, we sought to determine if simulation-based training could be effective in teaching medical students how to be active bystanders.
Our study aims were:
To develop a simulation-based active bystander training (ABT) session for medical students.
To evaluate the impact of this training using a validated questionnaire developed as tool of assessment for our students.
Methods
ABT is part of the wider equality, diversity and inclusivity (EDI) programme embedded into the curriculum throughout years 1–5 in our medical school, under the auspices of General Practice, Communications Skills and Professionalism.11 This training includes flexible but compulsory e-learning modules in year 1 and two large group interactive webinars on ABT and Cross Cultural Communications delivered in year 4 of the curriculum.12 All students who participated in the sessions described below had recently completed the interactive webinars as well as the e-learning modules.
ABT development
An expert panel was convened to determine the content and format of the proposed small group simulation-based ABT sessions. The panel comprised the medical school leads for EDI, Communication Skills and Quality Assurance as well as colleagues with expertise and experience in professionalism teaching and in Simulation. Panel members were all active clinicians from a range of specialties including general practice, surgery, paediatrics, neurology, geriatrics, endocrinology, radiology and nursing. All members of the expert panels were asked to contribute exemplar scenarios of ‘difficult’ situations medical students could potentially encounter in the clinical environments. Those included could be examples of rudeness, clear discrimination or situations which were ‘uncomfortable’ in nature.
These scenarios were collated and formed the content pool from which video vignettes, immersive simulation and card games were chosen for filming, script development and printing.
A draft programme was agreed and delivered initially to the faculty described above to test content and format. The student voice was also represented in this session by medical students active in Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual (LGBTQIA)+ and disability/ability groups. This first run helped refine the material and approach, ready for use in the formal teaching sessions.
Questionnaire development
No suitable tool to evaluate our planned training programme was available at the time of the study. A further expert panel was convened to develop a bespoke tool suitable for evaluating the planned simulation-based ABT sessions. The panel consisted of medical educators from our Institution, spread across a range of clinical practice. Details of the panel and questionnaire development process can be found in online supplemental appendix 1.
Supplemental material
The resultant questionnaire comprised 11 questions/statements—10 of which had 100% consensus for inclusion while 1 had 89% concordance. The final questionnaire is shown in online supplemental appendix 2.
Students are asked to rate each question/statement on a five point Likert scale. The first cohort of students was invited to complete the preintervention tool twice, approximately a week apart, to help determine the internal consistency and stability of the tool prior to training.
Simulation-based ABT: session description
Fourth year students attending three hospitals for medicine and surgery placements were invited to each session. After completing the preintervention questionnaire(s), these students were given a small reference book on antiracism and a link to an antisexism game as preparation to their ABT session.13 14
The sessions comprised:
An interactive introduction to recap students’ learning to date, emphasising the role of effective communication skills, using the ABC approach and ‘4D’s’ framework of how to be an Active Bystanders12 (15–30 min).
Watching prerecorded video vignettes (×3 cases).
Playing an ABT themed card game (variable number of cases dependent on time).
Immersive simulation (×2 cases).
Summary with ‘take forwards’ messages from students.
Close.
The card game involved students picking a random card from the stack and reading out loud the workplace scenario (akin to an abridged immersive simulation ‘plot’) written on it. The groups were asked to consider if the described behaviours were appropriate, if not why not (‘name it’) and what strategies (the ‘4Ds” framework) an active bystander could potentially employ. Facilitated discussions were conducted after each scenario in segments (2)–(4). Further details can be found in online supplemental appendix 3.
Student preference and protected characteristics
Students were asked to rank their preference of the proffered activities on the day (Introduction, Video Vignette, Card Game and Immersive Simulation)—most (1), quite (2), somewhat (3) and least helpful (4).
Students were also asked if they self-identified as having a protected characteristic and provide feedback, including suggested improvements.
Response to these questions was optional.
Institutional board review was sought for this work but waived as it was undertaken as planned curriculum development and considered part of normal and expected education evaluation process.
Statistics
Bland and Altman limits of agreement were computed for the two preintervention questionnaire scores to determine how consistent questionnaire responses were over time. The change in total questionnaire scores preintervention and postintervention were analysed using a paired t-test. All analyses were done using Minitab (V.18) at a 5% significance level.
Results
Questionnaire validation: internal stability
Matched pairs of preintervention questionnaires were collected from the first cohort of medical students (N=22) who participated in this programme.
Limits of agreement were used to determine the agreement between the questionnaire scores on the two occasions. The mean difference between attempts 1 and 2 was just 0.04 (95% C.I −2.36 to 2.45)—suggesting excellent internal consistency (figure 1).
The boxplot shows the distribution of total scores on the two baseline questionnaire attempts. The hypothesis being that total scores are equivalent.
Outcome after simulation-based ABT session
A total of 66 medical students from 3 teaching hospitals attended seven 3-hour sessions. The average number of students attending each session was 9 (range 7–12).
The questionnaire was completed with matched pairs of preintervention and postintervention scores by 58 (88%) students. There was a significant increase in the total scores after the intervention (p<0.001) for all statements [including ‘I feel able to act as a bystander if I witness harassment or disrespectful behaviour’] except statement 5 (‘I know when physical contact is inappropriate’) (table 1).
Change in scores for each question
The mean preintervention score was 38.2 (SD 5.9) out of a maximum score of 55. This compared with postintervention score of 49.1 (SD 4.8). The mean increase in total score postintervention was 11.0 (95% C.I 9.4 to 12.5; p<0.001) (figure 2).
Boxplot of total scores preintervention and postintervention.
Student preference and protected characteristics
Thirty-nine students ranked their preference for the different proffered activities. Immersive simulation was ranked as most or quite helpful by 29 students, compared with 26 for video vignette (p=N.S.).
Thirty-eight (69.1%) of 55 students who answered this optional question self-identified as having a protected characteristic, with 2 students choosing ‘prefer not to say’ on their forms. We received 33 (50%) free-text comments about these sessions from students. A summary of the collated themes from their feedback is tabled (table 2) and selected comments are listed in online supplemental appendix 4.
Students comments—summarised theme of feedback comments (N=33)
Discussion
This study demonstrates that medical students significantly improved their total scores after attending small group ABT sessions on how to be active bystanders. This, to our knowledge, is the first study to evaluate the use of simulation to teach medical students how to be active bystanders. This study has also developed a stable tool to evaluate simulation-based ABT.
This questionnaire identified significant self-rated deficits among medical students, particularly in the knowledge of the nine characteristics protected under the UK Equalities Act 2010 and the set of skills that can be used when witnessing harassment or disrespectful behaviours. This occurred despite repeated exposure to compulsory online as well as written material on EDI in their medical school curriculum, before this training session.
Our ABT session deliberately included varied tools of simulation (immersive role play, reading out scenarios and watching filmed video vignette) to appeal to different learner preferences as well as to gradually build students up towards more challenging immersive simulation situations. Our group agreed the minimum personnel required per session were two topic-expert group facilitators, two actors (for our chosen scenarios) and an AV technologist to handle the technological requirements to broadcast live video from the simulation room to the main group.
The time and resource required to develop and deliver such a training programme, each spanning approximately 3–4 hours, is not insignificant. Although students ranked the immersive role play most highly, it was in practice difficult to get students to volunteer on the day to participate in these segments. It is also the most expensive component of the session. Given the minimal difference in student preference between immersive simulation and video vignette, omitting the immersive simulation component may be an option if curriculum space and economic resource are limited.
Our findings build on previous work establishing simulation as an effective tool when teaching communication skills. It supports the premise that simulation-based ABT could help students develop the ability to recognise unprofessional behaviour and learn the communication skills required to be effective active bystanders. Knowing how to support recipients of unprofessional behaviour—through reporting and formal channels was also recognised as important.
Despite the 2010 Equality Act, there remains acknowledged unacceptably high levels of discriminatory, harassment and bullying behaviour in the workplace. It is time, given GMC’s new initiatives and mandates, for medical educators to effect culture change with a ‘bottom up’ approach—through our medical students. Culture change requires every student or doctor, wherever they are in the medical hierarchy, to understand what constitutes unprofessional behaviour and know that there can be no tolerance of inappropriate behaviour in the work environment.15 The role of the active bystander in this challenge has been highlighted as key.1
Postpandemic, the UK is facing a medical workforce shortfall crisis. A recent BMA survey of over 4000 junior doctors found 4 in 10 are actively planning to leave the National Health Service as soon as they can find another job.16 17 While 85% cited the current level of pay as the main reason, deteriorating work conditions (83%), lack of recognition of good work (72%), worsening personal well-being (70%) and worsening culture of workplace (61%) were also listed highly.
A culture of professionalism is undoubtedly crucial in retention, recruitment and better mental health at work—as stated by the US surgeon general in his 2022 public health report.18 Poor professional behaviour in the healthcare workplace affect team performance and potentially patient outcomes.19
Psychological safety (for students and faculty) was paramount for the sessions to be authentic and effective. Students were advised by email prior to the session, as well as verbally on the day, that the material being discussed could be potential upsetting. Students were encouraged to contribute and engage as they felt able in the facilitated discussions. They were also informed it was acceptable to not actively participate if that was preferable; that they could take time out and that a quiet room was available if required. They were reminded of the multiple ways they can get in touch with members of the Medical School Faculty to discuss any issues raised by the session, with particular emphasis on the school’s ‘Raising Concern’ online form.
The Socratic Method of elenchus was adopted during discussions (‘advocacy inquiry’ process of simulation debrief)—never didactic teaching nor shaming, disrespecting participants—rather a collective student-teacher and teacher–student exploration.20 21 The exception being when students misconstrued disrespectful behaviour as ‘par for the course of the hidden curriculum of medical hierarchy’, where clarification regarding boundaries was necessitated. Our experienced medical educator-facilitators were thus key in this process—with more than one present to allow ‘sense checking’.
Students appreciated the participation and informality of well-known senior members of the medical school. They felt this contributed to the authenticity of the sessions as well as signalling genuine commitment by the medical school to improve the culture and experiences of students while on clinical placements.
Of interest, was the apparent widespread unfamiliarity of the students with our ‘Raising Concerns’ online form as a means to highlights issues to the medical school. This occurred despite this resource being highlighted verbally and in writing on numerous occasions over the previous 3 years and also during the large group webinar a month prior to the training sessions. It served as a reminder of the importance and value of repeating ‘important’ information in multiple media, as no one method is infallible.
One of the strengths of our study is the diverse panel of experts we drew on to develop and deliver these training sessions. The diversity of experts was not confined to merely protected characteristics, but also included professional expertise, medical students and a lay person to give as wide a perspective as possible of different stakeholders in this educational activity. This diversity afforded authenticity and was likely a factor in both the resultant stability of the evaluation tool developed as well as the impact of the training on student’s scores. It is also worth noting a high proportion of these otherwise unselected students self-identified as having a protected characteristic. This reflects published data on the diverse make-up of our NHS workforce and the importance of policies to develop a more inclusive, diverse and equitable workforce at every level of the NHS.22
A potential limitation to the study was that just 88% of students completed the preintervention and postintervention questionnaires. This reduced the total number of potential data points we could have analysed and may have inadvertently introduced bias in the form of the self-selection of respondents and students who voluntarily participated in the training sessions. Nevertheless, our completion rate is extremely high when compared with other studies and would have limited any potential bias.
Another potential limitation was faculty members, types of discussions and number of card game scenarios discussed were different between sessions. This resulted in a ‘non-standardised’ teaching intervention that was being evaluated across the period of study. However, this was deemed a reflection of ‘real-world’ teaching and serves to demonstrate that the training programme was effective despite the non-uniformity and lends it well to potential transferability and sustainability beyond this small study.
Future work could evaluate the efficacy of the training programme if rolled out across the whole year group (circa 400); the efficacy of this/similar training programme delivered without immersive simulation or at a different medical school. This would allow for external and geographical validation of the questionnaire, as well as the potential role of interprofessional learning of this material. We are planning to evaluate longer-term impact with follow-up focus group discussion and questionnaire.
Conclusion
We found significant deficits in medical students’ self-rated knowledge of recognising disrespectful behaviour at work, particularly with regard to protected characteristics. Simulation in active bystanders training was effective in reversing this. This is a timely study given the new responsibilities placed on doctors by the GMC to act when witnessing discriminatory behaviour or harassment at work.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors CC, PO'D and DY contributed to the planning, conduct and reporting of the work described in the article. CC, PO'D, DY, ET, KC, LP, CP, EL, IH and FN contributed materially to the paper. All other contributors who do not justify authorship have been acknowledged in the Acknowledgement section. CC, guarantor.
Funding This study was funded by Association for the Study of Medical Education(Excellent Medical Education Award).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.