September 22 2022

Zero tolerance for bullying in healthcare?

Roger Kline, MDX Research Fellow, argues tackling bullying and harassment in healthcare must remain a priority and equal more than well-meaning statements of planned action

Five years ago, Duncan Lewis and myself estimated the bullying of NHS staff in England cost £2.3 billion per year – and this didn’t include the huge cost of presenteeism (working without being productive), incivility (rude behaviour), or the impact on bystanders. It took no account of primary care or national bodies and above all it did not include the immense cost to patient care. We were told “NHS bosses will be sacked if they fail to stamp out alarming bullying of hospital staff”. Since then the incidence of bullying, and the likelihood staff will report it, has remained at dangerous levels.

In the last NHS staff survey 11.6% staff reported at least one incident of bullying, harassment or abuse by a manager, whilst 18.7% reported at least one incident by another colleague.  Less than half (48.7%) said that they or a colleague even reported such incidents. Some groups of staff (disabled, LGBT and Black and Minority Ethnic staff) remain especially subjected to bullying, harassment and abuse whilst it is particularly high in some occupations, notably the ambulance service. We now also know how toxic rudeness is.

Bullying has been a key factor in patient care scandals driven by a cocktail of workload pressures, reorganisations, hierarchical cultures, and poor leadership which together create an organisational climate in which inappropriate and unacceptable behaviours become the “norm”. It is a serious problem for the NHS. It damages the health and wellbeing of staff.  It undermines organisational effectiveness, increases sickness absence, prompt presenteeism, and reduce discretionary staff effort and increasing turnover not only of those directly subjected to bullying and harassment but bystanders too.   It undermines effective team working, disrupts inclusive working, and negates psychological safety which in turn undermine the trust, collaboration and communication essential for good care.

If it is such a problem why have efforts to reduce it failed?

Almost seven years ago the NHS Call to Action on Bullying made little difference. NHS Employers bullying guidance (2006-2016) stated ‘employers can only address cases of bullying and harassment that are brought to their attention’.  This approach emphasised the importance of making it safe for staff to raise concerns, of having policies, procedures and training in place, often accompanied by leaders (and ministers) announcing “zero tolerance” of bullying.

But staff who are bullied and harassed are reluctant to formally complain because they either have no confidence it will make a difference or believe it will make things worse. I recall how, when visiting one NHS trust with poor staff survey bullying data, I was assured this data should be treated with a degree of scepticism as there were very few grievances lodged. I suggested this meant there was a further problem – staff saw little point in raising concerns or were afraid of the consequences of doing so.

Research finds the reliance on policies, procedures and training to be fundamentally flawed. An authoritative ACAS review concluded, for example

“while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace …….. research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces.

The review added such an approach

“flies in the face of current research evidence about the limited effectiveness of using such individualised processes to resolve allegations of bullying and to prevent bullying behaviours.”

Organisational culture is shaped by formal organisational values and local policies; by values, behaviours and knowledge staff learn; and by how an organisation’s leaders behave. Culture is crucial in healthcare. Managing staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates, Care Quality Commission (CQC) ratings and financial performance.  

An inclusive climate (the antithesis of an inclusive one) is more likely to enable psychological safety and both are likely to positively influence speaking up and may be particularly helpful in the hierarchical environments common in healthcare where it may minimise the effect of status on psychological safety within teams and give legitimacy to voice. Inclusive teams treat relational intelligence (kindness, emotional intelligence) as being important as rational intelligence (regulation, measurement and efficiency) further enabling those benefits.

Using formal grievance procedures to tackle bullying is rarely effective. Employees who “win” often find they have to “move on” whilst employers find underlying causes are rarely addressed. My own field work suggests staff who do raise bullying concerns want bad behaviours to stop rather than to lodge formal grievances. Grievance, discipline and whistleblowing procedures which are often linked to bullying concerns risk a punitive and adversarial approach driven either by an eye on possible litigation – or the silencing of the person raising a concern.

There is an alternative, but no magic solution. The NHS has shown a growing interest in data-driven early informal intervention – a “public health” approach to toxic culture. The ‘professionalism pyramid’ developed by Vanderbilt University’s Center for Professionalism and Patient Advocacy, for example, emphasises discussing unprofessional behaviour at the first signs of it and providing support for the individual to change whilst emphasising the need for interventions to escalate if unprofessional behaviour persists or worsens. A review found the majority of professionals “self-regulate”. 

Such informal early action, appears to rely on managers, senior staff, HR and staff as a whole:

  • Being clear about the importance of responding to low intensity or one-off behaviours such as rudeness and interpersonal conflict;
  • Having the confidence, skills and time to make effective informal early interventions.
  • Having (and be seen to have) the active support of senior leadership modelling such behaviours

Without those preconditions being in place staff may fear becoming a target themselves, or making things worse. Early research on the impact of bystanders emphasised “the relevance of workplace relationships and managerial ideology in influencing bystander decisions, actions and outcomes. “

Another element of early intervention may be the use of mediation but ACAS advise caution against using mediation as a universal “fix” especially where there are stark power imbalances between the parties.

Research on whistleblowing (a frequent way of staff raising concerns about bullying and harassment) by Megan Reitz and colleagues concludes

“leaders…..are focusing their attention and efforts predominantly on those who feel silenced, urging them to ‘be brave’, ‘speak up’ and have the ‘courageous conversations’ that are required…….We need to stop trying to ‘fix the silenced’ and rather ‘fix the system’.”

Reitz then argues

“instigating whistleblowing lines and training employees to be braver or insisting that they speak up out of duty, will achieve little therefore, without leaders owning their status and hierarchy, stepping out of their internal monologue and engaging with the reality of others.”

In whistleblowing, in discrimination and in bullying (which often overlap) what leaders do, and don’t do, is what drives culture, not what they say. There certainly are some NHS leaders who behave like corporate psychopaths. But many others want to do the right thing but hesitate or struggle.

Accountability is crucial. The approach to workplace culture in Mersey Care NHS FT suggests some principles we might draw on, acting wherever early, informally, using data and soft intelligence to be preventative and proactive with an emphasis on learning not punishment. Recent resources from NHS England helpfully build on elements of that approach in tackling incivility and rudeness at work.

Finally, there is much talk about “allyship” in tackling discrimination. This approach applies equally to bullying and harassment. It should not (must not) be left to those who are bullied and harassed to have prime responsibility for tackling their abuse. It is for leaders to step up and for all of us as colleagues to do the same, early and informally wherever possible, robustly where that is not possible. Crucially, we must draw on the evidence relying primarily on policies, procedures and training is simply not good enough and, in isolation, simply will not work.

Roger Kline is Research Fellow at Middlesex University Business School

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