Intended for healthcare professionals


Bullying in health teams undermines patient care, finds study

BMJ 2016; 353 doi: (Published 28 April 2016) Cite this as: BMJ 2016;353:i2450
  1. Matthew Limb,
  2. freelance journalist
  1. BMJ Careers
  1. limb{at}

Bullying relationships between junior doctors and nurses are common and often interfere with patient care, researchers studying teamwork in healthcare settings in Ireland have found.

Researchers at the National University of Ireland, Galway, and Trinity College, Dublin, said that action should be taken to target key areas of poor teamwork performance, such as poor communication, that pose higher risks to patients.

The researchers collected and analysed examples of poor teamwork in the Republic of Ireland and published their findings in the International Journal for Quality in Healthcare.1

The study involved 28 interns in the first year of clinical practice and eight qualified nurses at two large teaching hospitals, all of whom worked on either a surgical or a medical ward. The relationship between nurses and interns was seen as key because the first doctor to be called by a nurse to evaluate a patient is often the most junior.

In interviews, they described 33 scenarios of poor teamwork. The interviews were coded against a theoretical framework of healthcare team function by three psychologists and were also rated for risk to patients by four doctors and three nurses.

“Poor quality of collaboration” was the most commonly identified cause of poor teamwork within the scenarios, seen in 21 out of 33 cases (64%). The results showed that “conflict and bullying” were also features of the relationship between nurses and interns, and that these behaviours “interfered with patient focused care.” Just under half of the scenarios (48.5%, 16 out of 33) were attributed to a “lack of coordination.”

Interns and nurses have different, and sometimes competing, goals that can compromise team coordination, the researchers said. “Poor leadership” was identified as a contributing factor in 14 of the 33 scenarios (42.3%).

Assessors used risk ratings to identify the teamwork failures that had the greatest potential to result in patient harm. None of the scenarios emerged as low risk, 17 scenarios emerged as medium risk and 16 scenarios as high risk.

High risk situations were more likely to be caused by “poor situation awareness between team members and a lack of communication,” such as a failure to share information about patients.

A “lack of shared mental models” was identified, meaning that doctors and nurses differed in their understanding of the situation or actions needed.

The authors said that effective teamwork between junior doctors and nurses was crucial to patient safety and quality of care although there was no simple solution to improving teamwork.

They said, “Our research identifies a ‘lack of shared mental models’ and ‘lack of communication’ as the teamwork problems which pose the greatest risk to patient safety. Thus, effective interventions designed to improve teamwork performance in these areas must be developed and evaluated.”

They said that more should be done to develop the team skills of doctors and nurses and “foster a clinical environment in which teamwork is supported.”