November 14 2016

Bullying puts patients at risk

Roger Kline Middlesex UniversityRoger Kline, co-author of Professional Accountability in Social Care and Health: Challenging Unacceptable Practice and Its Management, suggests National Anti-Bullying Week should be a cause for reflection in health and social care.

The NHS is England’s biggest employer and offers a service almost everyone uses. Overwhelmingly NHS staff enter healthcare because they care. Yet the last NHS staff survey of 300,000 personnel found that the proportion of NHS workers experiencing harassment, bullying or abuse from fellow staff in the last 12 months has now risen from 14% (2010) to 24% (2015). In the same year just 41% (down from 55% in 2010) of those experiencing or witnessing such harassment bullying and abuse from staff said they had reported it, a significant fall.

The scale of the problem

In other words, more staff are telling the confidential NHS staff survey that they themselves have been bullied in the last 12 months, but the proportion of staff who say they have reported this bullying to their employer has fallen. Staff with disabilities, LGBT staff and BME staff all suffer very significantly higher levels of bullying than the average.

This matters for three reasons. Firstly, the growing mismatch between available resources and growing healthcare demand alongside the resultant uncertainty due to reorganisation has placed both staff and their managers under greater pressure than ever before. Such an environment is a breeding ground for bullying.

Secondly, the HR paradigm that had been used is one where the employer establishes policies, procedures and training, but it is down to individuals to raise any concerns. As I have argued elsewhere, and as research confirms, such an approach is likely to fail. Staff generally do not report bullying because the consequences of doing so can make things even worse. Moreover by individualising bullying, such an approach ignores the evidence that it is organisational climate that is decisive in allowing bullies to bully without fear of being held to account.

Surgeon stock image

Patient safety

The third reason gets surprisingly less attention in the UK. NHS employer bullying policies hardly mention (if at all) the damaging impact of the bullying of staff on patient care and safety. Research on bullying in the NHS has largely done the same. Thus, the otherwise excellent most recent review of the literature on bullying in the NHS states “the impact on patient care and performance was not directly measured although references to performance impairment, such as the inability to think straight described above, were common”.

Yet the evidence of the impact on patient care and safety is not new. The inquiry into baby deaths at the Bristol Royal Infirmary a decade ago warned of the impact of bullying, and in 2009 Sir Ian Kennedy, who chaired that Inquiry, said: “One thing that worries me more than anything else in the NHS is bullying … We’re talking about something that is permeating the delivery of care in the NHS” (Santry, 2009). Evidence commissioned by Lord Darzi in 2008 concluded there was a “pervasive culture of fear in the NHS and certain elements of the Department for Health”.

We know that staff who are bullied will be less likely to raise concerns, less likely to admit mistakes and less able to work in effective safe teams. Mary Dixon-Woods and colleagues found lower levels of mortality were associated with higher levels of ‘staff engagement’ (the antithesis of bullying in some respects) and concluded that “the wellbeing of staff is closely linked to the wellbeing of patients, and staff engagement is a key predictor of a wide range of outcomes in NHS trusts. Achieving high levels of engagement is only possible in cultures that are generally positive, when staff feel valued, respected and supported, and when relationships are good between managers, staff, teams and departments and across institutional boundaries”.

Michael West and colleagues similarly found that “bullying, discrimination, and overwork lead to disengagement and “are likely to deprive staff of the emotional resources to deliver compassionate care”.

West and Dawson used NHS staff survey and patient survey data to analyse the links between staff engagement, patient experience and outcomes.  They found that engagement is significantly linked to patient mortality in NHS acute trusts, both when mortality is measured in the same year as engagement, and when it is measured in the subsequent year. Specifically they found:

  • a strong negative correlation between whether, in the NHS staff survey, staff reported harassment, bullying or abuse from other staff and whether patients reported being treated with dignity and respect
  • a strong negative correlation between whether staff report harassment, bullying or abuse from other staff in the NHS staff survey and overall patient experience in 2011.
Photo by Benjamin Ellis - Creative Commons 2.0

A London ambulance responds to a 999 call – Photo by (Creative Commons 2.0)

Engaged staff were more likely to intervene to raise concerns about safety or address poor behaviours. Their analysis of the NHS staff survey shows a strong positive correlation between staff engagement and the percentage of staff reporting that they reported errors, near misses or incidents in the past month in the NHS staff survey for 2012. They concluded that “engaged staff may provide our most efficient mechanism for addressing negligence or poor standards of care”.

So, when the NHS national staff survey also tells us that alongside the increase in bullying and the decline in the reporting of bullying, there was a significant decline from 2011 onwards in the proportion of staff who said they reported safety incidents, we should be concerned.

In the USA, the Joint Commission issued a July 2008 Sentinel Alert entitled ‘Behaviors that undermine a culture of safety’. It was able to draw on extensive research about the consequences for patients of bullying. According to one US survey, 49% of clinicians felt pressured to dispense or administer a drug despite serious and unresolved safety concerns, and 40% have kept quiet rather than question a known intimidator. Other studies have shown that recipients of abusive behavior learn to cope by avoiding the abuser, even if this means failing to call when warranted and avoiding making suggestions that might improve care. In one study, 17% reported that an adverse event occurred as a result of disruptive behaviour.

Other research considered the role of human factors and their effect on patient safety and clinical outcomes of care. Rosenstein found that problems with disruptive behaviour negatively affect communication flow and team dynamics, which can lead to adverse events and poor quality outcomes and concluded “disruptive behaviours increased levels of stress and frustration, which impaired concentration, impeded communication flow and adversely affected staff relationships and team collaboration.”

Research over a 10-year period looked at the consequences of poor communication, a particular consequence of bullying, on adverse events. It reported that communication failure was:

  • The primary cause for medication errors, delays in treatment, and surgeries at the wrong site and
  • the second leading cause of operative mishaps, postoperative events and fatal falls.

US patient safety authority Lucien Leape found that disrespect in medicine is a threat to patient safety because “it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices”.

Australian researchers reached similar conclusions earlier this year. “The impact of poor occupational health and safety is felt not only by the affected staff, but also by the patients they are treating … Health sector organisations with strong staff safety cultures have fewer patient safety incidents, and the incidents that do occur are of shorter duration. Stronger management of bullying and harassment would benefit patients as well as staff.”

Ministers have been planning an initiative on bullying in the NHS for some considerable time. It remains to be seen whether it will highlight the impact on patient care and safety that the bullying of staff has. If it does, it will command much more board attention. If it doesn’t the narrative will be much less powerful. It would have even more impact if ministers stopped the widespread perception amongst Trust chief executives that much bullying comes from the very top of the NHS, in Richmond House. Sir Robert Francis’ 2015 report on whistleblowing had an excellent section on the impact on patient safety of the bullying of whistleblowers but reference to that disappeared in the government response.

Three surgeons in the operating room

So what’s gone wrong?

Every NHS organisation has a policy declaring zero tolerance for bullying and harassment and trains its managers in how to apply the policy. But research makes clear that reliance on individual staff complaining about bullying is a strategy doomed to failure, yet that is how many NHS organisations still operate. I have argued elsewhere that has to change and it is starting to change.

However unless, in addition, the impact on patient care and safety of the bullying of staff becomes central to our thinking, bullying in the NHS will never get the attention it deserves. The immense pressures on workloads, job security and constant restructuring within the NHS and social care encourage bullying, but the evidence of its negative impact is now clearer than ever. Unless healthcare providers accept the research evidence and make patient care and safety central to the reduction of the bullying of staff (as the best ones already do) we will struggle to achieve Robert Francis’ aspiration in his Public Inquiry Report in 2013:

“The common culture of caring requires a displacement of a culture of fear with a culture of openness, honesty and transparency, where the only fear is the failure to uphold the fundamental standards and the caring culture.”

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