MEETING REPORT

Dysfunctional work and learning environments: Lessons from non-medical settings. 21st annual symposium of the Ibadan Medical Specialists Group, UK, at the College of Medicine, University of Ibadan, Nigeria, on 10th November 2021

The 21st annual symposium of the Ibadan Medical Specialists Group (IMSG), United Kingdom, took place at the Paul Hendrickse Lecture Theatre, College of Medicine, University of Ibadan (COMUI), Ibadan, Nigeria, on 10th November 2021, and by Zoom Webinar to an international audience.

The creation and protection of ideal work and learning environments is garnering attention, and the absence of well-crafted mandates leaves room for hostile workplaces that have led to loss of life. Hierarchical social systems such as the police force, armed forces, and in medical training and workplaces are prone to a culture that aids and abets unhealthy, counterproductive and expensive behaviours often under the guise of routine ‘chain-of-command’ action. Individuals who occupy the lowest rungs have demanded and rightly deserve protection of their human dignity from each level of the hierarchy. The challenge in healthcare requires consequential, actionable codified procedures with external oversight, across silos of care, making leaders duty bound at every level, to reward (and penalize) validated feedback from anyone in their system.

Dysfunctional Work and Learning Environments – Global Case Studies, was the lecture by Mr. Olufunso Adedeji, Consultant Colorectal Surgeon, University Hospital of North Durham, UK. He declared that Mr. George Floyd, the African American killed by the knee of a law enforcement officer in May 2020 in Minneapolis, United States, died because of abuse of power by an officer, in his workplace, who owed him a duty of care. The events that occurred laid bare the consequence of dysfunctional environments coupled with ineffective laws.

He explained that in the United States, where more than 30,000 people were killed by the Police between 1990 and 2018, rising to greater that 1,000 deaths per year between 2015 and 2021, during which more than 200 victims had toy guns and more than 400 had no weapons, and yet, from 2005 to 2019, only four police officers have been convicted of murder. Mr. Floyd’s killer was empowered by his certainty that he would legally get away with murder, as he nonchalantly and publicly knelt on Mr. Floyd’s neck for 9 min and 29 sec. He wondered when ineffective laws enabled power abuses that kill, how much more bullying and harassment, where the laws are even less effective. At the centre of toxic work or learning environments is power abuse, he said.

Ineffective laws, toxic work environment and abuse of power create the substrate for a psychopathological problems, and Herbert J. Freudenberger (1975), a German-American psychologist, described toxic work culture as a workplace blighted by abusive relationships, where bullying and harassment from senior staff, as well as narcissism among leaders, aggressive behaviours and cynicism reign. A progression of this, based on work by Heinz Leymann (1990), a German-Swedish psychologist, was moral harassment (mobbing and sham processes), a combination of workplace bullying and psychological terror perpetrated by a group of people in a systematic way over a prolonged period to force a person out of the workplace. This formed the basis of the French moral harassment Labour Code, Article L.1152.1, which Mr. Adedeji described as the most progressive law in the world on workplace bullying and harassment. Under its criminal code, it carries up to 2 years in prison. Under this law, three directors of France Telecom (previously Orange) were found guilty of the suicides of 35 employees, and the chief executive was sentenced to 4 months in prison and fined $16,000 in 2019.

In a 2018 review of 79 papers by Bambi et al., 68–90% of nurses experienced incivility, up to 87% lateral violence and up to 81% bullying with physical and mental sequelae including post-traumatic stress disorder. In the United Kingdom, 23% of workers reported that they have been bullied, and 25% have been made to feel left out.

He illustrated the ineffectiveness of the law in toxic work environments in the United Kingdom with three examples. Mr. Amin Abdullah, 41, a nurse at Imperial College Healthcare NHS Trust, committed suicide by self-immolation in 2016. He was dismissed after 3 months of investigations. An independent investigation showed that the evidence submitted to the hearing panel did not paint an honest and complete picture, and that Mr. Abdullah had been the only person out of 19 signatories of a petition to have been investigated. He said that despite the House of Lords (now Supreme Court) ruling in 2008 that employers owe employees a duty to foresee the risk of suicide secondary to work-related depression (Corr v Ibc Vehicles Ltd. 2008), and an obligation on the state to protect Mr. Abdullah’s right to life under Article 2 of the European Convention on Human Rights, the post-humous remedy Mr. Abdullah got was an apology from the chief executive for their mistakes. The implied similarity between the reasons for Mr. Floyd’s and Mr. Abdullah’s deaths, and the differences in outcomes are clear.

In the second case, Mr. Reuser (a surgeon) sued the University Hospital Birmingham (UHB) NHS Foundation Trust in 2018. The judge accused the Trust of giving the General Medical Council and the National Conciliatory Advisory Service (NCAS) inaccurate and misleading information, and accused them of bias, incompetence and collusion at senior management level against Dr. Reuser, and that his exclusion was a sham. Whilst the judge found in favour of Dr. Reuser, he applied a legal Polkey principle of 1987 in deciding compensation and ruled that Dr. Reuser contributed 50% to his predicament. This, Mr. Adedeji argued, was the law blaming a victim of abuse. He pointed out that whilst Dr. Reuser was still going through the courts, the medical director who gave evidence for the Trust is now its chief executive, and he wondered how a safe working environment could flourish. He also noted that in the same Trust, three doctors committed suicides between 2015 and 2018, and he lamented that United Kingdom does not investigate suicides in working age adults. Again, the implied differences in outcomes for leaders of UHB and those of the French Telecom were clear, as it is arguable that UHB leaders breached the French moral harassment law.

The third case was of Dr. Wendy Potts, a 46-year-old general practitioner who hanged herself in 2015. She was being investigated because she had written a blog about her mental health. The coroner noted that the investigation process lost sight that Dr. Potts was a human being and noted the concern that hospital investigations were taking place on a day-to-day basis.

Mr. Adedeji concluded his lecture by suggesting reasons why abusers who create toxic work environments think they can get away with it. These include a sense of entitlement, lack of effective censure (legal and workplace), group think (workplace leadership culture and bystanders), lack of knowledge including ineffective definitions, and amorality. Moving forward, he advocated a worldwide adoption of the French moral harassment law, universal forensic investigations of all suicides and the designation of work-related mental morbidity as occupational diseases that should have meaningful compensation.

Professor Eme Owoaje, Consultant in Community Medicine, University College Hospital, Ibadan, Nigeria’s lecture, was Learning Environments for Medical Students in sub-Saharan Africa: Has Progress Been Made in the Last Decade? A passionate advocate for medical students said the learning environment plays significant role in the professional and moral development of students, and supporting environments are essential for effective medical education. She addressed the role of validated questionnaires for the assessment of educational, physical and psychological environment using the Dundee ready educational environment measure (DREEM; Roff et al. 2009).

In a review or reports from Nigeria, South Africa, Zambia and Uganda, most students perceived learning environments as positive. However, barriers to learning included overcrowding, mistreatment, lack of social support systems, dictatorial staff and poor feedback culture. A review across four geographical areas in Nigeria revealed that one of the most common forms of students’ mistreatment is public humiliation during teaching. These manifest as shouting, belittling and being assigned tasks as punishments, a practice described as toxic in focused interviews. There is a misperception that such public humiliations lead to improvement in future performances, and most of the perpetrators were senior doctors and consultants.

A surprising finding in these reviews was the perception by medical students of poor teaching and mentoring skills in Nigeria, Zambia and Uganda. Professor Owoaje shared some focused interview comments, a Ugandan fourth-year student,

‘Someone can excel academically but they don’t know how to teach, when they don’t have the heart to teach so I think it is better for us to have somebody who can teach us whether they are excellent or not…,’

and from a fifth-year student,

‘I think the first thing they should do is to first reorient the lecturers, the doctors or workers, on their duties besides seeing patients, they should be taught how to teach. They should train them every year like in seminars.’

Professor Owoaje listed the progress over the last decade, which included the introduction of medical education units, medical partnership education initiative in sub-Saharan Africa, white coat ceremonies, curricula review, counseling units and mentoring programs. However, further attention is needed to focus on students feeling distant, dictatorial systems still in place, limited teacher feedback, subjective student assessments, restrictive marking system, inter-cadre wrangling and sexual harassment. A way forward will be implementation of policies and procedures for reporting incidences of mistreatment, bias or harassment, and how to deal with them. It is noteworthy that Professor Owoaje received a standing ovation from all the medical students who were present at the symposium.

Clinical Benefits of Safe Working Environments were addressed by Dr. Abiodun Fakokunde, Consultant Obstetrician and Gynecologist, North Middlesex Hospital, London, UK. Clips of Sir Lancelot Spratt, the irascible surgeon at a fictitious London hospital in the British film ‘Doctor in the House’ (1954), set the tone for how behavioural modelling influenced a generation of doctors, albeit incorrectly. In the United Kingdom, bullying and harassment is estimated to cost the National Health Service (NHS) more than two-billion-pound sterling. Engaging students in the clinical learning environment and an investment in the academic, technologic as well as health and wellbeing and sense of community are but some steps to secure the future of the positive learning environment. Those positive learning emotions benefit high level of cognitive processing, metacognitive learning, facilitate use of cognitive process and student motivation for learning is enhanced. It reduces error rates, stress, injuries and bullying and harassment and further reduces patient mortality in the acute care. Pride in self and community and hope in creating a more inclusive and safer environment will be essential to secure the benefits to patients and staff alike. Links to resources at the RCOG (Royal College of Obstetrics and Gynaecology) were shared: https://www.rcog.org.uk/en/careers-training/workplace-workforce-issues/.

In a talk entitled ‘Psychological Sequelae of Dysfunctional Work and Learning Environments’, Dr. Jibril Abdulmalik, Consultant Psychiatrist, University College Hospital, Ibadan, Nigeria, reminded the audience of the World Health Organization (WHO) definition of health focused on the domains of mental, physical and social wellbeing. Like three cogs in a wheel, that a disorder of one invariably leads to disorders of all three, was illustrated with vivid clinical vignettes. The sequelae included cognitive difficulties, poor sleep, irritation, worry, stress, loss of confidence and also included anxiety, depression, suicidal behaviour, substance abuse, burn-out and impaired quality of family relationships. Countering these would be healthy behaviours including cultivating good human relationships including family, regular exercise, prioritizing sleep and sleep hygiene, and compartmentalizing. And life has ups-and-downs, so be kind to yourself and enjoy the ups whilst it lasts and know the next one is only a cycle away. The power of making good choices concluded the talk.

Major-General (Rtd) Akintunde Akinkunmi, former Chief Medical Officer (Reserves), British Army and Consultant Forensic Psychiatrist, UK, opened the final talk ‘Getting a Grip: The British Army Experience in Tackling Bullying and Harassment’ with quotes from the Joint Service Publication 763 of the British Army Reserves, ‘Unacceptable behaviour will NOT be tolerated’, ‘Everyone has a duty to challenge unacceptable behaviours’. Definition of bullying was adopted from the Advisory, Conciliation and Arbitration Service (ACAS),

‘unwanted behaviour from a person or group that makes someone feel uncomfortable, including feeling frightened (intimidated) or less respected (degraded) or upset (humiliated)’ He continued that bullying includes ‘ridiculing or demeaning…overbearing supervision or other misuse of power and position…preventing individuals progressing or pressuring someone into not making a complaint.’

He said that the most effective way to discourage unwanted behaviours is to incentivize its cessation, and at the same time, make its continuation detrimental to whoever does it. The onus was placed on commanders to effect this. This was a data-driven process, with data from Company, Battalion, Brigade and Divisional levels, as well as in Corps and Regimental Headquarters. Reporting was both vertically in the hierarchy and horizontally. The annual appraisal reports for Officers and Non-commissioned Officers included new domains to reflect the number of bullying and harassment cases reported from their units/formation, and the resolution rates for the complaints make. These were taken into consideration at appointment and promotion boards. In the first 24 months, there was a drop of around 38–56% of cases of harassment and bullying.

A service complaints Ombudsman was appointed from outside the Army to provide independent and impartial scrutiny on how the Army handled service complaints. Military Court Centres were set up, with court martial presided over by non-military judges. Variety of penalties included loss of seniority, reduction in rank, dismissal, fines and imprisonment. There were also direct and personal consequences for Commanders at all levels who failed to robustly deal with complaints of bullying and harassment and was a powerful incentive to getting a grip.

During the lead-in to the symposium, Mr. Adebanji A. B. Adeyoju, President IMSG and consultant urologist, Stockport NHS Foundation Trust, Stockport, UK, recalled the founding of IMSG in 1994 and reported a donation to the University of Ibadan Medical Students Association, and a commitment to fund indigent medical students to the tune of 2.5 million Naira annually for the next 3 years. Despite overwhelming interest in the indigent medical students’ fund, 53 vetted indigent student applications have been received, and final selections will be announced by the college.

Professor Olayinka Omigbodun, Provost, and Professor of Child Psychiatry, COMUI spoke of the need to aspire for excellence and be hopeful in a youthful nation where nearly 200 million individuals are under 25 years, with their power to transform the future. Dr. Boluwatife Ikwunne, 2019 MBBS graduate, with distinction in Psychiatry and Rhodes Scholar, was recognized, and the provost made the case for engineering the environment where medical students can and must thrive. The availability of a counselling service for medical students was announced, as but one step aimed at the theme of improved environments in medicine, and ultimately the task of nation building.