As well as a moral issue, tackling racism affecting NHS staff is a crucial part of improving patient safety and care, says MDX Research Fellow Roger Kline
There is finally a growing awareness of the impact of discrimination on Black and Minority Ethnic patients.
There is equally a growing awareness of the scale of race discrimination in all aspects of the lives of citizens of Black and Minority Ethnic heritage including the quarter of a million Black and Minority Ethnic staff working in the NHS.
Not so well known is the impact of race discrimination against health and social care staff on the care and safety of all patients and service users.
We have a wealth of data demonstrating that BME staff in health care are disadvantaged in recruitment and career progression, in whether staff are disciplined, bullied and harassed at work, and are treated worse if they raise concerns or admit mistakes.
Such treatment demoralises staff, wastes talent, affects turnover, costs money, and damages staff health. But crucially it also undermines team working, incentivises blame, not learning, and adversely impacts patient health and safety.
Risk one: There is a serious risk that recruitment and promotion data means that selection panels may be choosing “people like us” or who can best “fit in” rather than the best candidates, thus depriving patients of the best possible talent.
The NHS has an ethnicity gradient in which the more senior the post the less likely we are to see BME staff. It is still 1.61 times more likely that a White shortlisted candidate will be appointed compared to a Black and Minority Ethnic shortlisted candidate. It is not surprising therefore that it is twice as likely that BME staff do not believe there are equal opportunities for promotion and career progression.
Risk two: A culture of blame not learning is a risk to patient care and safety
NHS BME staff are more likely than White staff to be disciplined. They are more likely to be reported to their professional regulator by their employer (though interestingly, not by the public). BME staff are more likely to be bullied by managers and colleagues than White staff and are three times more likely to report being discriminated against than their White colleagues.
Literature demonstrates the risk of racial bias in investigations. In combination, such treatment means it is more likely that the mistakes we all make are seen through the lens of blame, not learning for BME staff, not least because of the difficulty some White managers have in having honest conversations with BME staff.
Risk three: Racialised patterns of work are a risk to staff health and adverse impact on staff health may have consequences for staffing absence, discretionary effort and staff turnover, any of which may impact on patient care and safety, especially at a time of pre-existing staff shortages
Racialised patterns of employment were highlighted during Covid. According to Public Health England researchers, almost 90% of staff infection was due to occupational exposure. BME staff were disproportionately impacted because:
- They work disproportionately in lower-graded patient facing roles
- They had poorer access to appropriate PPE with the correct fit
- They were more reluctant to raise concerns
- They were disproportionately redeployed to riskier areas
- Agency staff (more likely to be BME) may not have been reimbursed when self-isolating or had poorer access to PPE.
More generally, we know that race discrimination makes people ill. Two decades ago, in journal article Agency and structure: the impact of ethnic identity and racism on the health of ethnic minority people, Nazroo and Karlsen found that:
“Over and above socioeconomic effects, both experience of racial harassment and perceptions of racial discrimination make an independent contribution to health. For example, those who had been verbally harassed had a 50 per cent greater odds of reporting fair or poor health compared with those who reported no harassment”.
Race discrimination is positively associated with an extensive range of adverse conditions including coronary artery calcification, high blood pressure, lower birth weight, cognitive impairment, and mortality. Moreover, discrimination, like other stressors, can affect health through both actual exposure and the threat of exposure.
Risk four: If BME staff are more likely to be bullied that will impact on their health and their working lives as well, placing patient care and safety at risk
BME staff are 21% of the NHS workforce. An astonishing 28% of them reported being bullied and harassed by managers and staff last year, significantly more than White staff reported themselves as being (23%).
The adverse impact of bullying on staff health has been well evidenced by Lever and others and in turn impacts on performance, career progression, engagement, retention and team effectiveness, as well as harming the safety and physical and mental well-being of staff.
American medic Lucien Leape describes how a culture of 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”. Staff who are bullied are less likely to admit mistakes, raise concerns or work effectively in teams – all with consequences for patient care and safety.
Risk five: If staff are less likely to speak out and raise concerns that is likely to directly impact on patient care and safety
Robert Francis’ Speaking Up report (2015) drew on a survey of 20,000 NHS staff which found very significant differences between the experiences of White and BME staff who raised concerns.
It was 50% more likely that:
- BME staff raising concerns would be satisfied with the response to their concern about suspected wrongdoing
- BME staff felt they would be victimised by management after raising a concern
- BME staff felt they had been victimised by co-workers after raising a concern
- BME staff were 23% less likely than White staff to report a concern again if the staff suspected wrongdoing
- BME staff were 70% less likely than White staff to raise a concern about suspected wrongdoing, due to a fear of victimisation.
The NHS National staff survey 2020 reported a significant difference between White and BME staff views on raising concerns. It reported that staff from BME backgrounds are less likely (62.1%) to feel safe to speak up about any concerns than White staff (67.0%).
Risk six. Where staff of Black and Minority Ethnic heritage are not welcomed, their difference valued, and it is not a safe place for them to raise concerns, then patient care is likely to lose the benefit that improved representation can give.
Dawson (2009) found that
“the experience of black and minority ethnic (BME) NHS staff was a good barometer of the climate of respect and care for all within the NHS. Put simply, if BME staff feel engaged, motivated, valued and part of a team with a sense of belonging, patients were more likely to be satisfied with the service they received”.
Similarly West, M et al (2018) found that
“the % staff believing Trust provides equal opportunities for career progression or promotion… was a very important predictor of patient satisfaction in all three analyses (2014, 2015 and across the years). The more staff believe this to be the case, the more satisfied patients will be on average.”
Racism and bullying undermine psychological safety at work. This matters because as Carter and colleagues demonstrated, inclusive and compassionate leadership helps create a psychologically safe workplace where staff are more likely to listen and support each other, resulting in fewer errors, fewer staff injuries, less bullying of staff, reduced absenteeism and (in hospitals) reduced patient mortality.
An inclusive work team recognises, as Edmondson (1999) puts it, the deep human need to belong, and the anxiety anyone may feel when speaking up or sharing ideas in front of others for fear of saying something that may appear stupid or wrong.
Inclusion may be regarded as the extent to which staff believe they are a valued member of the work group, in which they receive fair and equitable treatment, and believe they are encouraged to contribute to the effectiveness of that group. Inclusive workplaces and teams value the difference and uniqueness that staff bring and seek to create a sense of belonging, with equitable access to resources, opportunities and outcomes for all, regardless of demographic differences.
As Shore (2018) put it, Inclusive organisations are more likely to be ‘psychologically safe’ workplaces where staff feel confident in expressing their true selves, raising concerns and admitting mistakes without fear of being unfairly judged.
Or as Professor Scott E Page describes in The Diversity Bonus: How Great Teams Pay Off In The Knowledge Economy (2017) – when more diverse representation is underpinned by inclusion, demographic diversity can improve team performance. The evidence for this is more nuanced than is sometimes presented, but is convincing nevertheless. An evidence base supports the proposition that effective leadership is diverse, inclusive and compassionate.
Psychological safety and inclusion impact positively on organisational effectiveness. When more diverse representation within teams and in leadership are underpinned by inclusion, it is likely that performance will improve, creativity and innovation will be greater, turnover will reduce and risks will be better highlighted.
One senior BME nurse put it to me, “I’ve spent my entire career walking on eggshells knowing that should I make a mistake or raise a concern I will be held to a higher standard than my White colleagues. I have more than once joined teams where I am not fully valued for the difference I bring or the insights I can share. Inevitably this affects patient care and safety”.
Conclusion
Tackling racism is first and foremost a moral issue but it is also a crucial part of improving the care and safety of patients and service users whatever their ethnicity.
Employers have a duty of care and a statutory duty to address many of the drivers of staff discrimination. On the resultant risks to staff health, for example, doing so requires that they not only address the risks to individuals but the root causes of those risks. It was remarkable during Covid 19 how employers disproportionately focused on individual health risk assessments rather than exercising their duties under the Management of Health and Safety at Work Regulations (1999 as amended) which require employers to ensure there is a work environment that is, as far as reasonably practicable, safe and without risks to health.
Covid 19 and Black Lives Matter have finally, I think, led to many NHS leaders (not all) asking HOW they can address this issue as a priority, not WHY. To do so we have to stop leaving it to those adversely affected by discrimination to be the ones challenging it. We have to recognise that while overt racism is not normalised in the NHS, the patterns of bias, stereotypes, assumptions and behaviours that characterise systemic racism are well embedded and that they significantly damage patient care as well as healthcare staff.