Why bullying persists in surgery: governance, culture, and resources

What is it about?

This paper examines why workplace bullying continues to persist in surgical settings, even as awareness increases and formal efforts to promote respectful behaviour expand. Rather than focusing on individual incidents or personalities, the study explores the broader systems, structures, and conditions that enable bullying to take hold and endure. Drawing on the perspectives of senior surgeons across Australia and Aotearoa New Zealand, the research looks closely at three interconnected domains: governance, culture, and resources. These domains shape how power is exercised, how behaviour is interpreted, and how accountability operates in everyday surgical work. By examining bullying through this systemic lens, the paper seeks to explain not just what happens, but why change has been so difficult to achieve. Surgeons described governance arrangements that were often fragmented or ambiguous, particularly where professional authority, hospital management, and regulatory oversight intersected. Participants spoke of uncertainty about who was responsible for addressing harmful behaviour, inconsistent responses to complaints, and a perception that senior or high-status individuals were rarely held to account. These governance gaps were seen as creating space for bullying to persist, even in organisations with formal policies and codes of conduct. Cultural norms within surgery were also central to surgeons’ accounts. Many described a longstanding emphasis on toughness, endurance, and hierarchical obedience, often reinforced during training. While some surgeons noted generational shifts and increasing intolerance of overt bullying, more subtle forms of exclusion, intimidation, and silencing were reported to remain common. These behaviours were frequently normalised as part of surgical identity or justified by performance pressure and clinical risk. Resource constraints further compounded these dynamics. Surgeons linked bullying to understaffing, time pressure, unstable teams, and competition for operating time, training opportunities, and professional recognition. In these contexts, stress and scarcity were seen to amplify power imbalances and reduce the capacity of leaders and organisations to intervene early or effectively. Importantly, the paper shows how governance, culture, and resources do not operate in isolation. Instead, they interact in ways that can either reinforce or mitigate bullying. Weak governance allows cultural norms to go unchallenged. Cultural acceptance of hierarchy limits the use of formal mechanisms. Resource scarcity intensifies conflict and narrows the space for reflection or repair. By centring senior surgeons’ reflections, this study provides a grounded account of bullying as a systemic and organisational phenomenon rather than an individual failing. It offers insight into why policies and training alone are insufficient, and why meaningful change requires coordinated reform across leadership, governance structures, and resource allocation. In doing so, the paper contributes to a more realistic and actionable understanding of how bullying can be addressed in complex, high-stakes professional environments.

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Photo by National Cancer Institute on Unsplash

Photo by National Cancer Institute on Unsplash

Why is it important?

This paper is important because it explains why bullying in surgery persists despite decades of awareness, policy development, and targeted interventions. Rather than treating bullying as a series of isolated incidents or individual failures, the study reframes it as a systemic problem shaped by governance arrangements, cultural norms, and resource conditions. What makes this research distinctive is its focus on senior surgeons as sense-makers of the system. Senior surgeons occupy a pivotal position in surgical environments. They are both products of the system and key actors within it, responsible for leadership, training, and professional standards. By foregrounding their perspectives, the study provides rare insight into how bullying is enabled, normalised, or challenged at the level where cultural and structural forces converge. A central contribution of this paper is the introduction and application of the 3-1-3 model. This conceptual framework helps explain bullying as the outcome of interacting forces rather than a single cause. The model identifies three primary systemic drivers, such as entrenched hierarchy, ambiguous governance, and resource pressure. These drivers are filtered through one critical mediating factor, individual personality and identity, which shapes how power is exercised or resisted. The consequences then manifest as three outcomes, including harm to individuals, deterioration of team functioning, and risks to organisational performance and patient safety. This approach is unique because it bridges individual and systemic explanations without collapsing one into the other. It shows why some individuals perpetuate bullying within the same environment where others actively resist it, and why interventions that focus solely on behaviour change or training often fail to gain traction. The 3-1-3 model provides a practical way of understanding where interventions are likely to be effective, and where they are likely to be undermined by unresolved structural conditions. The paper is also important because it integrates governance, culture, and resources into a single analytical frame. Previous research has often examined these factors in isolation. By showing how weak governance allows harmful norms to persist, how cultural expectations discourage speaking up, and how resource scarcity intensifies conflict, the study offers a more complete explanation of why reform efforts so often stall. Ultimately, this paper matters because it moves the conversation from recognition to diagnosis. It provides a coherent, evidence-based framework for understanding bullying as a system-level problem that requires coordinated action across leadership, governance, and resourcing. In doing so, it offers a foundation for reform that is both theoretically robust and practically relevant, not only for surgery, but for other high-stakes professional environments where power, pressure, and identity intersect.

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