2025/02/16 by Britta S. von Ungern‐Sternberg, Karin Becke · 1 voice · 2 citations
Psychology · Health Professions · #Counseling Practices and Supervision #Mentoring and Academic Development #Healthcare professionals’ stress and burnout
paper · doi:10.1111/anae.16561
Doctors are often perceived as being noble and selfless, working hard for the benefit of others. For the vast majority of our colleagues, this image holds exactly true. They are wonderful people, full of empathy and energy, giving their best to improve patient care and outcomes. However, medicine seems paradoxically vulnerable to toxic leadership, which creates hostile work environments and compromises the quality of care, patient outcomes and staff wellbeing. Following our report on editorial misconduct [1], we received a lot of responses privately; many shared their experiences with authorship misconduct or, more generally, with academic misconduct. This was often accompanied and worsened by the devastating impacts of toxic leadership, making it even more difficult to speak up. Speaking up is even more daunting when the toxic leader is part of the hierarchy or a person of influence within the same organisation, who can take direct retribution and affect a person's reputation and career closer to home. The reports of toxic leadership were not only a recurring theme but were spread over a significant number of institutions and not limited to a particular area of the globe. What do we mean by toxic leadership? It is characterised by an abuse of power to the detriment of individuals, the team, the organisation and, potentially, society in general. Personal, sometimes hidden, agendas and personal advancement are prioritised over team success and the general organisational mission. Behavioural patterns often comprise arrogance, bullying, favouritism, micro-management and a general lack of empathy, leading to an erosion of trust, morale and staff efficiency. Kets de Vries describes the four main traits of toxic leadership the following way [2]: “pathological narcissists, who are selfish and entitled, have grandiose fantasies, and pursue power at all costs; manic-depressives, who can leave a trail of emotional blazes behind them; passive-aggressives, who shy away from confrontation but are obstructive and underhanded; and the emotionally disconnected—literal-minded people who cannot describe or even recognise their feelings”. Toxic leadership involves a complex interplay between the underlying mental health of the leader and the presence of these toxic traits. Additionally, these factors impact not only the mental health of senior leaders but also the work environment they create for everyone around them. Why is toxic leadership so common in medicine? Traditionally, many medical systems are hierarchical, which can, on the one hand, ensure accountability, but more importantly, it often shields toxic leadership behaviours. Speaking up for safety may be linked to too many negative consequences in an environment with toxic leadership. High-stress environments with long hours and high work pressures can not only take a significant emotional toll but also create a fertile ground for the manifestation of toxic traits. We all have our difficult sides and external pressures can expose them. While we went through medical and specialist training, the ‘tough love’ approach was common, leading to a normalisation of toxic behaviours. In fact, these toxic behaviours were often lauded as ‘resilience building’. Unfortunately, leadership training is still frequently not an integral part of our general training; leaders are often chosen based on clinical expertise and academic merits rather than on their abilities to lead. Without proper training in leadership, they may fall back on psychopathological behaviour patterns or on what they have learned and experienced during their junior years and unintentionally adopt harmful practices. Good doctors are not necessarily good leaders. We should strive for ethical leadership in medicine, which is characterised by six main principles [3] (Table 1). Respect: this includes valuing other people's skills and contributions. Medical leaders, traditionally, saw this as a one-way system (respect from their junior staff); however, in an ethical workplace, this respect must be mutual, leading to healthier workplace relationships, including the safety to speak up. A respectful workplace can drive safe patient care, increase staff wellbeing and consequently increase overall productivity and patient outcomes. Accountability: ethical leaders stand behind their actions and hold themselves accountable rather than searching for the famous scapegoat. Their decisions are based on integrity rather than personal gain, leading us to the third principle of service, where decisions are taken with the entire community in mind, not personal gain at the forefront. Service: ethical leaders prioritise making decisions that benefit employees, customers and the broader community. With these groups consistently at the forefront of their considerations, they demonstrate a deep commitment to service. Honesty: transparent leaders foster trust by communicating openly and honestly, empowering informed decision-making and strengthening both organisational integrity and long-term customer loyalty. Justice: this extends beyond legal compliance to ensuring fairness for all; ethical leaders prioritise equitable treatment, foster mutual respect and create inclusive work environments where everyone feels valued. Community: ethical leaders see their organisations as communities, fostering equity, inclusion, diversity and collaboration by considering the needs of everyone involved in their decision-making process. Toxic leadership in any healthcare environment creates significant challenges for team dynamics, patient care and staff wellbeing. Barriers to change often involve deeply rooted cognitive, affective and systemic factors [4-7] (Table 2). So, how do we foster a respectful collaborative work culture that values the principles of ethical leadership? We need to implement robust feedback mechanisms, encourage an open feedback culture including 360° feedback providing a comprehensive view of leadership behaviours, and create safe reporting mechanisms for staff to be able to report toxic behaviours without the fear of immediate repercussions for themselves, their teams and possibly even their family. Another important step to be taken is development of leadership training programmes, educating our existing leaders and training the leaders of the future (i.e. emotional intelligence training, conflict resolution skills, ethical leadership workshops). How do we cultivate a culture of psychological safety? We should focus on solutions rather than blame and judgement. Let's look forward to improving our systems, including normalising speaking up and encouraging open communication more generally. Providing multiple reporting avenues can be very helpful, offering anonymous reporting in parallel to standard direct communication channels. Some institutions have established integrity advisors who can assist and support staff, particularly those in a training position, students and early career researchers in cases of suspected misconduct. Additionally, wellbeing advocates within a department can help give an easy-to-access path at times of crisis for peer support. Let's grow a culture of true collaboration and teamwork, where bullying, fear as a motivator, nepotism and abuse of power which characterise toxic leadership are unacceptable and called out, rather than ignored or allowed to persist. Where staff feel respected and where our patients, their care and improved outcomes will be at the heart and centre of what we do, rather than individual people, their glory and gain. How can we overcome systemic barriers? We need to re-evaluate existing hierarchies and flatten them if necessary to promote collaboration and reduce power imbalances. Clear policies must be set up, defining acceptable and unacceptable leadership behaviours, including consequences for toxic practices. External support is useful for offering professional coaching, neutral mediation or external reviewing and providing objective recommendations. Shared leadership settings can be a great way to empower and engage a larger number of senior clinicians, and to drive diversity and collaboration within a department and distribute the work and ‘leadership power’ among more shoulders, taking pressure and power away from the overarching ‘chief’. What can we do as an individual? We can listen, we can acknowledge the concerns and help to the best of our abilities to take immediate and visible steps to help to find a resolution. But first and foremost, those of us who are in leadership positions should model proactive safety behaviour, address concerns and implement strict policies against retaliatory actions for reporting safety or integrity issues. We should make safety and integrity a regular topic and work on an inclusive culture where we look out for each other and address concerns collectively. This will lead to better functioning teams, boost staff moral and improve productivity. Addressing toxic leadership in clinical departments offers significant benefits [8-11]. First, it enhances team morale by reducing burnout, increasing staff retention and fostering collaboration. Second, it improves patient care through better focus, communication and continuity of care. Third, it strengthens organisational reputation, making departments more attractive to talent and trusted by patients. Fourth, it boosts productivity and efficiency by optimising workflows and reducing conflicts. Fifth, it fosters innovation and collaboration, empowering team members to propose ideas and work across disciplines. Sixth, it mitigates legal and financial risks by reducing turnover and litigation. Finally, it promotes a positive cultural shift, modelling ethical behaviour and psychological safety. Overall, addressing toxic leadership is a strategic investment in a department's long-term success as well as the retention and wellbeing of all staff. Change begins with a commitment to self-awareness and growth. Senior anaesthesia leaders must recognise the impact of their actions on the team and patients, while organisations must prioritise leadership accountability and cultural transformation. Practical measures like training, feedback systems and systemic reforms can help dismantle barriers to change and foster a healthier, more respectful work environment. As we have stated previously, “the core of academic medicine lies in serving our community. We are called to this field not for personal gain or prestige but to elevate our specialty and enhance patient outcomes. Our patients must be the cornerstone of every decision and action—it's about them, not us.” [1]. BvU-S is part funded by the Stan Perron Charitable Foundation and through a National Health and Medical Research Council Investigator Grant (2009322) and is also affiliated with the Perioperative Care Program, Perioperative Medicine Team, The Kids Research Institute Australia, Nedlands, WA, Australia. No other competing interests declared.