Why bullying persists in surgery despite reform efforts

What is it about?

This paper examines workplace bullying in surgery through a system-level lens, asking how broader organisational and structural conditions enable bullying to persist even when awareness is high and interventions are in place. Building on earlier work that documented surgeons’ lived experiences and evaluated the limits of training-based responses, this study shifts attention to the wider context in which those experiences and interventions are embedded. Drawing on interviews with senior surgeons across Australia and Aotearoa New Zealand, the paper explores bullying as a product of interacting influences across governance, culture, and resources. These three domains shape how power is exercised, how behaviour is interpreted, and how responsibility for action is assigned or avoided in everyday surgical practice. By focusing on these systemic conditions, the study seeks to explain persistence rather than prevalence. Surgeons described governance arrangements that were often fragmented or unclear, particularly at the intersections between hospitals, professional bodies, and regulatory systems. Participants spoke of uncertainty about who was responsible for addressing harmful behaviour, inconsistent responses to complaints, and a perception that authority and accountability were frequently misaligned. These governance gaps were seen to limit early intervention and allow problematic behaviour to continue without clear consequence. Cultural factors further reinforced these dynamics. Many surgeons reflected on deeply embedded norms that emphasised toughness, endurance, and hierarchical obedience, particularly during training. While participants acknowledged shifts in expectations and declining tolerance for overt bullying, they described more subtle behaviours such as exclusion, intimidation, and silencing as continuing under the guise of professionalism or performance pressure. These norms shaped what behaviours were challenged, excused, or ignored. Resource pressures added another layer of complexity. Surgeons linked bullying to understaffing, time constraints, unstable teams, and competition for operating time, training opportunities, and status. In these environments, stress and scarcity were seen to intensify power imbalances and reduce the capacity of leaders and organisations to respond consistently or effectively. A key contribution of the paper is showing how governance, culture, and resources operate together rather than independently. Weak governance allows harmful cultural norms to persist. Cultural expectations discourage speaking up or formal escalation. Resource constraints amplify conflict and narrow the space for reflection, repair, and leadership action. By situating bullying within this broader system, the paper provides a macro-level explanation that complements earlier micro- and meso-level findings. It demonstrates why policies and training alone are insufficient and why sustainable change in surgery requires coordinated attention to leadership authority, governance structures, cultural norms, and resourcing decisions. In doing so, it offers a more complete and realistic understanding of how bullying persists and what meaningful reform is likely to require.

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Photo by 刘 彦军 on Unsplash

Photo by 刘 彦军 on Unsplash

Why is it important?

This paper is important because it provides the system-level explanation that has been largely missing from efforts to address bullying in surgery. While earlier research has documented harmful behaviours, measured their impact, and evaluated specific interventions, these approaches alone do not explain why bullying continues to recur across institutions, despite sustained attention and reform. This study addresses that gap directly. By examining bullying through the combined lenses of governance, culture, and resources, the paper shows how organisational structures and conditions shape behaviour in powerful but often invisible ways. It demonstrates that bullying is not simply tolerated by individuals, but produced and sustained by systems that diffuse responsibility, normalise endurance, and constrain meaningful intervention. This reframing is critical because it shifts the focus of reform from individual behaviour to organisational design and leadership accountability. The paper is also important because it clarifies why well-intentioned policies and training programs frequently fail to gain traction. Surgeons described how formal expectations of respect were undermined by unclear authority, inconsistent responses to complaints, and informal power networks that operated beyond official governance. Cultural norms that valorised toughness and silence further discouraged reporting, while resource pressures intensified stress and competition. Together, these conditions quietly neutralised the intent of reform initiatives. Another key contribution of this paper is its sequencing. It builds logically on earlier work that examined lived experience and intervention responses, and demonstrates that those findings cannot be fully understood without attention to the broader system in which they occur. By moving the analysis to the macro level, the paper explains persistence rather than simply describing harm or evaluating isolated solutions. Importantly, this study centres the perspectives of senior surgeons, who occupy a pivotal position within surgical systems. As leaders, trainers, and cultural carriers, their insights reveal how governance, culture, and resources intersect in practice, and where responsibility for change is most effectively located. This insider perspective strengthens the credibility and practical relevance of the findings. Ultimately, this paper matters because it offers a more precise diagnosis of the problem bullying represents. Without understanding the structural conditions that enable harm, efforts to improve behaviour risk remaining fragmented and superficial. By identifying how governance arrangements, cultural norms, and resource constraints interact, the study provides a foundation for reform that is more aligned with how surgical systems actually function. In doing so, the paper contributes not only to research on bullying in surgery, but to broader conversations about culture change in high-stakes professions where hierarchy, pressure, and identity intersect.

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