Health & wellbeing Social commentary

Supporting Parents in the Digital Age

Today’s parents are facing many new challenges and safeguarding issues once their children become active online. Dr Jacqueline Harding has launched an online TV channel specifically for parents who are concerned about protecting their children online.

There’s little doubt that many parents are feeling overwhelmed about how to support their children in the digital age as confirmed by my own recent small scale study in 2018 and other larger studies (Livingstone, 2018).

In an attempt to meet parents’ needs using a familiar format and one that parents often feel is more accessible, Tomorrowschildtv was built as a pilot online channel for parents of children from birth to 18 years, with over 40 films designed to help and support parents in the digital age led by a former BBC presenter with parents, experts and children debating specific issues. It was filmed at Middlesex University by students and is launching 29th November 2019.

In agreement with Livingstone’s (2018) observations of the lack of support for parents, my study revealed anxiety right across all age ranges. Indeed, Ofcom’s study (2017) revealed a similar picture where more than three quarters of parents of 5-15 year olds have sought information about how to manage online risks.

Addressing Parents’ Concerns

In answer to questions about identification of specific help/advice regarding media that a parent might seek out regarding these matters, answers typically fell into the following four broad categories: safety; behaviour; time restrictions and educational opportunities.

Several parents expressed similar concerns and the need for sources of help around behaviour and media with most parents admitting to feeling like a ‘bad parent’ or wishing not to appear negligent (this was a reason for seeking help). Parents commented on the lack of advice available about suitable lengths of time for their children to spend on a particular media device:

“I need to know how much screen time is too much?”

Although overwhelmingly, parents were primarily concerned about online safety regardless of age, parents of younger children tended to speak of their fear increasing as their child matures. Typically, parents reported feeling anxious:

“Desperate, yes, I’d say I was desperate for help.”

“They are so quick… they minimize the screen…I need support from someone who knows about these things.”

“I won’t allow a phone until secondary school – it’s too worrying – although there is less about stranger danger nowadays it’s more fear about online.”

“I heard about a child in the media…they were bullied online and committed suicide… it’s so worrying.”

“I worry about YouTube videos with inappropriate content still coming up even with parental controls.”

“I’m worried about my child (six years old) and her use of apps to insult people.”

“Access to porn had such a bad impact on my child – it caused him to act up at a later age.” (child now 13)

“I caught my child being the abuser online – I was shocked…”

The study found agreement with Livingstone’s (2018:11) enquiry into where parents might turn for advice about digital media where answers differed according to the age of the child. Parents of younger children were more confident of where to search for help and spoke of seeking help on Google, Mumsnet, CBeebies, Facebook mums’ groups, forums, and from peers. Others suggested that the responsibility shifts to the child as they mature: “My own children will get advice when they are older at primary school.”

Parents of children in the 6-12 year age range spoke of going to the school and asking for help. This also correlated with Ofcom’s (2017) study, where 61% of parents seek help or advice from their child’s school. In the study a number of other parents felt unable to seek help from their own parents) as:

“They wouldn’t know what to do… all this stuff happened after their time,”

and continued by trying to offer suggestions such as: “Kids YouTube might help… maybe; or a neighbour?”

Parents of 12-18 year olds were the most puzzled and felt unable to think of where to begin to access help, and three parents with children ranging between 13 and 17 years, were openly bewildered about where to access help.

Feeling helpless

Ofcom’s recent study (2017: 209) found that ‘one in six parents of 12-15 year olds feel they don’t know enough to help their child manage online risks’. One parent stated: “I guess I feel pretty helpless.”

In response to questions around a dedicated online TV channel for parents providing support – the responses were overwhelmingly positive. Some participants were even anxious to ensure that other parents would know about the resource by suggesting that it must be discoverable. The majority of responses to the suggestion of an online video-based platform tended to suggest the level of anxiety that parents were experiencing:

“I’m desperate for help”

“Online TV great…so it’s available on my phone.”

“Definitely yes.”

In light of Livingstone’s (2018) comments: ‘parents have woefully few sources of support and advice when they have digital questions and dilemmas,’ the parents’ responses in our study were unsurprising.

Health & wellbeing

Researching survivor experiences of trauma

Mia Scally, Professor Joanna R Adler & Dr Miranda A H Horvath explore the risks facing researchers working with survivors of trauma, and what can be done preserve the researcher’s emotional safety.

‘Self-care is foundational to our power, our resilience, our creativity, our health and our collective impact. Just as a fire needs breathing space between the logs to burn, we need spaciousness in our days to be impactful and sustainable’Norma Wong

Research with survivors of any traumatic event or series of events can be an incredibly powerful experience. ‘Bearing witness’ to a survivor’s experience should not be undertaken without full consideration of the potential costs and challenges that might arise for both the survivor and the researcher, and the benefits of undertaking such research should be clear and justifiable.  This includes prioritising the emotional safety of the researcher as part of the design of a project and as a prerequisite for ethical approval, as highlighted by the World Health Organisation.

This blog post seeks to explore how a researcher might be affected by research with survivors and how this can be mitigated.

The research project

As part of my doctoral studies (supervised by Dr. Miranda A H Horvath and Prof. Joanna R Adler), I am investigating women’s experiences of child custody in the context of intimate partner violence and abuse (IPVA). This exploratory research will build on knowledge within England and Wales, where literature on this topic is limited. This mixed-methods research project combines secondary research (qualitative analysis of online posts) with both qualitative (interviews with survivors) and quantitative methods (a survey for professionals*) to form three interconnected studies. Study one was completed in 2017 and involved thematic analysis of 68 online public accounts and associated comments threads detailing female survivors’ experiences of the child custody process where IPVA has been present. Study two involves in-depth interviews with survivors of IPVA.

The interviews have been completed and this posting is being written as a reflection whilst embarking upon the analysis process. The interviews were recorded and transcribed verbatim, resulting in repeated exposure to the content of each interview. Although fewer in number than the 68 online accounts, engaging with women’s narratives first-hand and immersion in their accounts entails more emotional labour.  The interviews included descriptions of violence, deeply personal accounts from women experiencing distress and trauma, and suggestions of poor or limited professional responses that have resulted in feelings of frustration and anger (mostly for the survivors but also for me). ‘Bearing witness’ to these women’s lived experiences and their repercussions involved a great deal of personal navigation and active management.

This is not uncommon and other researchers have discussed various forms of emotional labour throughout trauma-related research. They argue that emotions are part of being human and that qualitative research requires you to view things from the perspective of the participant. Emotional labour in such research can include feeling and showing emotions (e.g. as part of post interview reflection, or during an interview itself), suppressing emotions (particularly in academia, rigour and emotion may be perceived as incompatible), and navigating these emotions as part of the research process (e.g. considering one’s own relationships in a different light).

I found myself experiencing each of these elements: feeling emotionally exhausted by the interviews, then subsequently by the transcription; avoiding writing in my reflective journal because I wanted to suppress these emotions; and finally, reflecting on how my world view might have changed as a result of what I now know. Some of these reactions can be explained as vicarious or secondary trauma and can result from one-off or repeated exposure to survivor trauma. Vicarious trauma (in this context) is defined as a reaction to or an alteration of the inner world of the researcher because of empathising with the survivor and their traumatic experiences (e.g. someone researching child abuse might become more protective of their own child). Secondary trauma can also result from such research and is characterised by a symptomatic response similar to post-traumatic stress disorder. This can include taking on the trauma of the survivor, avoiding the research that is the source of the secondary trauma, and experiencing symptoms such as sleep disturbance or hyperarousal.

Research has explored the impact of working in the field of violence against women on practitioners and clinicians. Vicarious trauma experienced by researchers is less well understood although, there has more recently been acknowledgement that ‘the role of a researcher is different from that of a clinician or counselor and potentially more traumatizing because of an inability to “help” the victim’ (p96). I found this particularly difficult to balance (partly as a result of my previous experiences in supporting survivors of violence and abuse) and I spent time reflecting on my role in this research and what I could do to ensure the women being interviewed were supported. Offering participants a debrief sheet that listed support services was helpful here (and also an ethical requirement). I also chose to send participants a copy of their transcripts prior to commencing analysis. Participants were able to add to these in a different colour so that they could continue their story beyond the time limitations of the interview. This came from one of the women in the study. The participant was frustrated because she had to leave but wanted to finish telling her story. I equally didn’t want to silence her story so this is the solution we arrived at together. Another survivor mentioned how helpful the interview experience had been for her and how much she gained from sharing her story with me. That was powerful and helped me in return because I saw that the research was able to give back. It was able to ‘help’albeit in a different way than that of a clinician or a counsellor.

Protecting the researcher

Through counselling, close supervision and a reflective journal I was able to identify and work through the emotions raised by this project. I am much more able to recognise the impact of research and I ensure that I practice appropriate self-care when this is necessary. I make sure to undertake only one interview or transcription per day for example, and I take the time to read non-academic books so as to recuperate. Some work has been undertaken to help identify what other researchers have found helpful to militate against some of the impact of research with challenging topics and this is briefly summarised below.

Preparation – knowing what to expect from the topic and preparing for the project is seen as key. Planning debrief sessions, regular meetings with the research team, reading around the topic, and considering the risks to researcher wellbeing are all vital. Risk assessments are usually conducted as part an ethics process and emotional wellbeing should be considered as part of this. In addition, when preparing for data collection, it is important to take into account how to schedule the interviews and allow time for reading, processing and engaging with the material generated. The consensus is that too much exposure to challenging content in one day can be overwhelming. Try to ensure that you only undertake one interview in a day and plan your day so that you have minimal work or research related activities for the rest of it. This also applies to transcription of interviews and taking breaks when reading data is particularly important in research in these domains. Participants in previous research also found that limiting exposure to challenging topics in the way of media/books/TV was helpful.

Formal and informal support – Having a range of sources of support is viewed as beneficial by researchers. Clinical supervision, regular meetings with research supervisors, ongoing counselling (don’t wait until you realise you need this to organise it), and debriefing sessions with colleagues are all cited as helpful forms of formal support. Informal support may include discussions with family and friends, colleagues or team members. Making time to process the impact of researching sensitive topics and having open discussions about this is important.  If you are a Middlesex University student undertaking research that explores sensitive or distressing topics, please see the Wellbeing team website to see what support the Counselling & Mental Health service can offer you. If you are a member of staff, you can access the employee assistance programme – Optum.

Know how to support survivors – Coles et al. (2014) highlight this for two reasons: it is important to understand the boundaries of your role as a researcher – you are not typically a counsellor and are unlikely to be able to make professional onward referrals. However, you can signpost sources of support and this may itself provide peace of mind for the researcher. Such signposting can be as simple as developing a debrief sheet for participants with sources of support – required for ethical approval to research with human participants and vital to minimise harm to survivors – and sharing the contact details or location of local support services.

Understand your limitations – Being clear with your supervisors and yourself about whether and how you are coping with challenging content is vital. This can require reflection and may be an ongoing process. Knowing when to stop a task that is causing you harm is important. Evidence around whether having experienced the topic you are researching places you at increased risk of vicarious or secondary trauma is mixed, however keeping a reflective journal can be helpful here. Try to spend ten minutes whenever you can, writing about your experience of doing research and the current task. Take some time to explore how you are feeling about the process, analysis or findings. This serves not only to safeguard your mental wellbeing but also to enable you to develop as a researcher. In qualitative research, reflecting on what you bring to the research is part of the process.

Self-care – Take some time to do something fun or relaxing and schedule this in. Going for a walk in the woods, spending an hour at the gym, reading a book, taking a long bath or going out for a nice meal – this will be different for everyone. For some helpful resources, see this Self-Care Starter Kit developed by the School of Social Work, University of Buffalo.

Research that matters – For some, knowing that the research will make a difference can help them cope with the content. Are you going to publish from the research? Is it going to help develop or evaluate interventions? Will it contribute to the literature or help develop policy? Keeping this in mind may help.

I keep a reflective journal, attend regular supervision, have ongoing counselling and like to watch far too much reality television – what works for you?

*If you are a professional involved in the child custody process and would like to contribute to this important research, please consider taking part in or sharing the following survey exploring beliefs and practice when it comes to custody decisions.

Acknowledgements: Thank you to Naomi Graham for kindly taking the time to read, comment on and reduce the word count of the first draft of this blog post (some would say this is the hardest part!)

Health & wellbeing

NMC Fitness to Practice: a radical change?

Roger Kline Middlesex UniversityIn this post Roger Kline, Research Fellow at Middlesex University Business School, examines a new consultation document from the Nursing and Midwifery Council, which includes long-overdue changes to the NMC’s Fitness to Practice processes.

On March 28th 2018 the Nursing and Midwifery Council agreed a public consultation document on Fitness to Practise that states there is a pressing need for further change to fitness to practise for the following reasons:

  • A growing body of evidence suggests that an unintended consequence of regulators’ current fitness to practise model is a culture of blame and denial. That runs contrary to the values of openness and learning that are central to a patient safety culture.
  • We know from our own research that black and minority ethnic nurses and midwives are more likely to be referred to us by employers. That disproportionality creates a perception of unfairness which, again, runs contrary to patient safety,” Paper NMC /18/33.

Step forward anyone who would have imagined this five years ago.

The regulators of UK healthcare professionals have been heavily criticised (including by me) in recent years. Those criticisms have included failing to get the balance right between blame and learning; an inability to hold employers and senior managers to account whilst drawing individual registrants into long and damaging processes which are not obviously in the interests of patients but are damaging to staff; not supporting whistleblowers who are referred to the NMC as punishment; not sufficiently taking account of the context (such as staffing shortages, or bullying) in which fitness to practice is questioned;  and failing to respond to patterns of the disproportionate referrals of black and ethnic minority registrants without questioning why patterns exist.

In some senses, the regulators have mirrored the failings of employers who themselves have too often focussed on individual blame rather than systemic failings, on individual lapses rather than the context which made shortcomings in practice likely. The pattern of disproportionate referrals of BME staff to regulators reflect the pattern of disproportionate disciplinary action against BME staff in the NHS.

Why a new strategy?

So what has led to this change?

Firstly, there is a growing understanding within healthcare that learning from mistakes and poor performance is rather more productive than finding scapegoats for what went wrong. Fifteen years ago An organisation with a memory emphasised the importance of understanding systemic shortcomings rather than individual errors. More recently the thinking of patient safety advocates such as Sidney Dekker and the relentless work of the Clinical Human Factors Group has been influential.

Secondly, is a growing understanding that how staff are treated is intimately linked to the care and safety provided to patients. Staff engagement, respect and compassion are good for staff and patient care and safety whilst bullying and discrimination are not just morally offensive but are unacceptable because they waste talent, damage staff health, increase turnover and absenteeism, and are linked to poorer and less safe care. In particular, strong correlation has been established between the treatment of Black and Ethnic Minority staff (one third of doctors and one fifth of nurses and midwives) and the treatment of (all) patients. This understanding has led to the NHS Workforce Race Equality Standard, and a strategy for leadership development that explicitly links this evidence to healthcare improvement.

Thirdly there is now an awareness that the previous (unevidenced) dominant HR paradigm of primarily relying on policies, procedures and training to enable individual staff to challenge bullying, discrimination or unfair treatment was unlikely to ever succeed.  Instead, the best employers are now emphasising the employer’s responsibility to proactively intervene, prevent (not just respond to) unfair treatment and to try to ensure staff are treated fairly.

Parallels with disciplinary action

There are important overlaps between these themes which can decisively help in reducing levels of bullying, tackling discrimination and reducing the scale of unnecessary disciplinary action in the NHS, and in particular the disproportionate impact of such action on BME staff.  Early evidence from a number of NHS trusts suggests, for example, that inserting some form of accountability prior to any disciplinary investigation being started would help shift the focus from blaming individuals to considering system failures that are the predominant causes of errors. Together with applying the science of “human factors” which focusses on system shortcomings not just individual failings might allow healthcare employers to follow the expectation of the courts that they stop their “knee jerk” use of disciplinary suspensions.

It is much more likely that BME staff will enter the disciplinary process, and research suggests a prime reason for this is the failure of managers, at the point at which when errors or poor performance occur, to have the same informal and honest conversations with BME staff that they should normally expect to have with white staff. A small but growing number of NHS Trusts have demonstrated that radical reductions in the levels of disciplinary action, and not only for BME staff, can be achieved in ways which also prompt learning, not blame.

The nursing regulator sees the light too

I know from discussions with the NMC that their new strategy is in part a response to these developments. It is also a response to research commissioned by the NMC in which Elizabeth West and colleagues confirmed the nature and scale of disproportionate referrals of BME staff from employers, but interestingly not from members of the public.

The paper approved by the NMC Council on March 28th rightly states that:

“We consider that effective and proportionate fitness to practise means putting patient safety first, and that an open, transparent and learning culture will best achieve this. We are not alone in thinking that a culture of blame and punishment is likely to encourage, cover-up, fear and disengagement.”

It goes on to explain that:

“To achieve these aims, we need to take a consistent and proportionate approach to fitness to practise. We also need to be fully transparent and accountable… We will need to deal with concerns when they are serious enough that we need to take regulatory action to ensure patient safety, or because they cannot be managed locally… In these types of cases we should take into account the context in which patient safety incidents occur and also enable registrants to remediate concerns at the earliest opportunity. Then we should only hold hearings where there are real areas of dispute to be resolved.”

New strategic principles

The proposed strategy sets out its two “desired regulatory outcomes” as:

  • “A professional culture that values equality, diversity and inclusion and prioritises openness and learning in the interests of patient safety.”
  • “Being fit to practise means that a registrant has the skills, knowledge, health and character to do their job safely and effectively.”

The consultation document sets out a number of (welcome) strategic principles which include:

  • “Fitness to practise is about managing the risk that a registrant poses to patients or members of the public in the future. It isn’t about punishing people for past events.”
  • “We will take account of the context in which the registrant was practising when deciding whether there is a risk to patient safety that requires us to take regulatory action.”
  • “We may not need to take regulatory action for a clinical mistake, even where there has been serious harm to a patient or service-user, if there is no longer a risk to patient safety and the registrant has been open about what went wrong and can demonstrate that they have learned from it.”

The paper argues there will always be instances where disciplinary action by employers and regulatory action by the NMC is appropriate:

  • “We will always take regulatory action when there is a risk to patient safety which is not being effectively managed by an employer.”
  • “Deliberately covering up when things go wrong seriously undermines patient safety and damages public trust in the professions. A registrant who does so should be removed from the register.”
  • “We will only take regulatory action to uphold public confidence if the regulatory concern is so serious that otherwise the public would be discouraged from using the services of registrants.”
  • “Some regulatory concerns, particularly if they raise fundamental concerns about the registrant’s professionalism, can’t be remedied and require removal from the register.”

A change of culture

The paper calls for “a professional culture that values equality, diversity and inclusion and prioritises openness and learning in the interests of patient safety” and explains that:

“When looking at harm, we need to differentiate carefully between accidental errors or failures in the system, and deliberate or reckless behaviour and those who conceal patient safety concerns… Maintaining public confidence in the professions doesn’t mean that we need to punish people when something goes wrong. Making a registrant go through a lengthy fitness to practise process just to punish them would be counterproductive, given that a blame culture undermines patient safety.”

The paper continues:

“Research also tells us that our current fitness to practise processes don’t contribute to a healthcare culture that values diversity, equality and inclusion. There is an overrepresentation of registrants from outside the EU and from black and minority ethnic (BME) backgrounds in fitness to practise proceedings, driven by disproportionate referrals from employers.”

This is not just an issue for nursing and midwifery registrants. The paper notes that:

“This is a concern in other parts of the regulatory sector. General Medical Council research found that BME and non-UK doctors are overrepresented in investigations, (General Medical Council: ‘The state of medical education and practice in the UK 2015’  (pp. 58- 83) ) while five years of General Dental Council hearings data reviewed by the British Dental Journal in 2009 showed that dentists trained outside the UK made up 42% of registrants charged (Singh et al ‘A five-year review of cases appearing before the General Dental Council’s Professional Conduct Committee’ British Dental Journal vol 206 no. 4 Feb 28 2009).

The PSA too

At its Board meeting the week previously the Professional Standards Authority (the regulator of professional regulators) finally moved in a similar direction by including a new draft Standard 3 on diversity, for consultation, which adds a new requirement that:

“The regulator understands the diversity of the registrant population and its service users and ensures that its processes do not impose inappropriate barriers or otherwise disadvantage people with protected characteristics”.


This changed paradigm for the regulation of nurses and midwives is very welcome. However, setting out the new strategy is one thing, applying it may be another. To do so successfully will inevitably mean the NMC will need to:

  • Query why some employers have much higher levels of referrals than others and what the implications for a learning culture are
  • Ask some employers why BME nurses and midwives are being disproportionately referred. NMC investigation panels and staff will need to rethink how every referral is handled
  • Insist on greater diversity on panels and amongst senior staff at the NMC
  • Query employment practices within some employers which discriminate against some BME registrants (deliberately or otherwise)
  • As the strategy itself explains this will involve the NMC “holding full hearings only in exceptional circumstances”
  • Acknowledge the evidence that referrals can seriously damage the health of nurses and midwives most of whom are cleared eventually of any breach of the NMC Code.

There are elements of the report which need scrutiny, notably regarding transparency in those hearings that do still take place. But, in my view, this welcome consultation document signals that the NMC is now serious about adopting an evidenced approach which draws on human factors and the evidence of discrimination. At a time of immense pressures on front line staff and their managers it has never been needed more. The real test now is whether this change of direction in policy can be effectively translated into improved practice. For that to happen will requiring not only holding the NMC to account, but the leadership of nursing and midwifery throughout this land. Read it and decide for yourself.

Read the full consultation document ‘Ensuring patient safety, enabling professionalism’ on the NMC’s website

Roger Kline is Research Fellow at Middlesex University Business School. He was previously joint director of the NHS Workforce Race Equality Standard implementation team. He was co-author with Michael Preston Shoot of Professional Accountability in Social Care and Health: Challenging unacceptable practice and its management (Sage. 2012)

Health & wellbeing Social commentary

Equality in the NHS: a work in progress

Roger Kline is Research Fellow at Middlesex University Business School and was joint director of the NHS Workforce Race Equality Standard Implementation Team from its formation until September 2017. Roger is also the author of The Snowy White Peaks of the NHS (2014) that prompted the creation of the Standard.

The NHS Workforce Race Equality Standard (WRES) Data Analysis for 2016-17 records progress made in the world’s largest single current intervention intended to tackle workforce race equality.

Its publication comes weeks after the Civil Service adopted an approach to workforce race equality which draws on similar principles.

Both interventions are significantly different to most previous public sector interventions. There are some early signs that in the NHS the approach may be starting to work, albeit with much to do.

Portrait Of Female Nurse Wearing Scrubs In Hospital

First, the good news

For the third year running since the WRES was agreed in 2014, there was a significant increase in the number of black and minority ethnic (BME) nurses and midwives on more senior grades (Para 6.1.9). About half of all nurses and midwives are on Band 5, the entry Band, where the proportion of BME staff has been steady. However, the number of BME nurses and midwives joining Bands 6 and 7 in 2015-17 was double that of 2014; whilst for Band 8a the number of BME nurses and midwives joining trebled in 2015-17 compared to 2014, though improvement in the most senior grades was less marked. Almost 2000 more BME nurses and midwives have been appointed to more senior grades over this three year period than would have been the case if appointments had not markedly increased since 2014-15.

While the precise reasons for this improvement need further inquiry, the only significant driver since 2014 that might have impacted on the grading of BME staff was the WRES. There were no obvious demographic reasons to explain this change.

Secondly, while it remains 1.38 times more likely that BME staff will enter disciplinary investigations compared to white staff, this is a significant improvement on last year’s data which showed it was 1.56 times more likely they would do so. (Para 6.3.2). There is much more work to be done here, but innovative work is underway to level this particular field, some of which was summarised in Para 7.2.2 of last year’s report.

Thirdly, the 2017 analysis reports an increase in the number of Very Senior Managers (VSM) – above Band 9 – from BME backgrounds of 1.2%. This is welcome but for NHS trusts nationally, across the non-medical workforce (clinical and non-clinical), the proportion of BME staff in Bands 8a-9 and VSM was still only 10.4% compared with 16.3% in the workforce as a whole.

Finally, there is also a significant increase in the number of BME board members in Trusts but this increase is primarily amongst non-executive members, not employed executive Board members (Para 6.9.2).

Big challenges remain

Firstly, for BME staff the likelihood of being appointed from shortlisting has not improved at all (Para 6.2.2). It is still the case that white staff (across all grades) who have been shortlisted are 1.6 times more likely than BME staff to be appointed even once shortlisted, whereas the likelihood of white and BME staff being appointed should be the same. The scale of this challenge – a priority for the NHS – is shown by NHS staff survey data reporting that despite an improvement, it remains twice as likely that BME staff, compared to white staff, do not believe there are equal opportunities for career development and progression (Para 6.7.2).

Secondly, there is no significant improvement in the scale of bullying of BME staff, or on whether BME staff continue to report they are discriminated against (Para 6.8.2). The gap between the percentage of white and BME staff experiencing harassment, bullying or abuse from other colleagues in the last 12 months actually increased slightly (Para 6.2.2).

Finally, there remain marked differences between regions and types of Trusts. The London region remains significantly worse in its treatment of BME staff, something that is hard to understand given the self-evident importance of BME staff within London’s NHS. The ambulance sector remains an outlier on several indicators, though this is also the case for the treatment of white as well as BME staff.

An approach which is having an impact

Notwithstanding the scale of the challenge that still remains, the WRES is already having more impact than previous NHS interventions. What distinguishes the WRES from previous interventions in the NHS is that its approach is evidenced. It draws on three strands of evidence. The first was the Audit Commission report “The Road to Race Equality (2004) which I’ve discussed previously. The second was the impact of linking the Athena Swan Charter to access to NHS research funding. The third strand was partly summarised in a review of the wider international evidence on what works in equality, which emphasised mandation.

In light of this, the WRES was designed to:

  • be mandatory not voluntary
  • be subject to inspection linked to either sanctions or incentives
  • focus on measurable outcomes not just on improved processes
  • have a credible narrative, supported by leaders, that articulates diversity as a high institutional priority
  • place accountability at the centre of the development of specific initiatives to achieve these outcomes.

Such a question meant that clarity on what type of interventions might work became essential. The “shared characteristics” of effective interventions became a substantial part of the second WRES Data Analysis report on the 2016 data (April 2017) and sought to summarise the international evidence on “what works.” Seven key characteristics were identified:

  • Acknowledge the challenge – avoid the temptation to “ascribe more weight to positive information about the service than to information capable of implying cause for concern” (Francis 2013);
  • See workforce equality as integral to service improvement not just compliance – as an integral part of providing better services and improving staff well-being, not as a separate discrete task;
  • Insist on detailed scrutiny of data from Employee Staff Records and national staff survey data to identify the specific challenges that Trusts as a whole, or individual departments or services or occupations may have on race equality against the Standard. Accept that while data can identify patterns and hotspots of good and poor practice – root cause analysis may well be needed to understand it;
  • Ensure that the narrative underpinning strategy is specific to each organisation and work to ensure it is understood not just by Boards but by managers and front line staff;
  • Learn from previous failed approaches which relied on policies, procedures and training which will not work in isolation while relying on individual members of staff to challenge discrimination. Methodological individualism, which relied on individual members of staff raising concerns, complaints or grievances was not a strategy that was ever going to be effective. Leadership meant organisations must take prime responsibility, for example, for talent management and career development and be proactive in developing staff and challenging discrimination, in a radical break with the culture of allowing panels to appoint “people like us” or those who might  “best fit in”;
  • Specific interventions must be evidence driven and able to answer the question “why do you think this will work?” since unless that question can be answered replication is hit and miss;
  • Above all, accept that accountability is crucial. Unless leaders model the behaviours expected of others and face uncomfortable truths, and insist on evidenced interventions with locally developed targets, the best intentions will not bring about change.

Research and interviews with private sector organisations undertaken in 2016 confirmed such principles had some likelihood of success.

In the foothills of the Snowy White Peaks

The NHS is England’s largest employer of black and minority ethnic staff – 37 per cent of doctors, 20 per cent of nurses and 17 per cent of all directly employed staff are from black and minority ethnic (BME) backgrounds. Research has consistently shown the NHS treats black and minority ethnic (BME) staff less favourably than white staff not only in recruitment, promotion, career progression and discipline but also in referrals to professional regulators. BME staff are also more likely to be bullied at work and treated less well when they raise concerns. NHS Boards at every level, and in both executive and non-executive positions, are disproportionately white and often unrepresentative of the local populations served by NHS Trusts. The large scale NHS national staff survey (340,000 responses) suggests the perceptions of BME staff are well grounded.

If the approach taken through the WRES in 2015-2017 is sustained there can be some confidence in further improvement. It would have been good to have had an updated version of the section in the April 2017 data analysis report which set out at length the “shared characteristics” of effective interventions, since without such work there will always be a risk that work to improve workforce race equality can drift into an emphasis on good intentions and “cultural change” rather than practical support for interventions that work.

We are still in the foothills of the “Snowy White Peaks of the NHS” but this report suggests the original WRES architecture was sound and that sustained improvement is possible, even though there is still a very long way to go.

Health & wellbeing

Rethinking disciplinary action in the NHS

Roger Kline Middlesex UniversityRoger Kline is Research Fellow in the Business School at Middlesex University, and was joint Director of NHS Workforce race equality Standard implementation team until last month. Here, he outlines the cost of disciplinary investigations and puts forward a case for more learning and less blame when mistakes are made.

No one knows how much NHS time and energy is wasted on unnecessary disciplinary investigations, suspensions, hearings, and appeals, but it is a lot. When the National Audit office took a look at one small aspect of the cost in 2003, they found 1,000 clinical staff suspensions averaging 47 weeks for doctors and 19 weeks for other clinical staff at a cost of £40 million in just one year.

The total cost of unnecessary disciplinary investigations, suspensions, hearings, and appeals for all staff groups are included, and is many times higher today, especially when supplemented by unnecessary referrals to professional regulators and the additional cost of related sickness absence, staff cover, early retirement and turnover.

In too many organisations moving to a formal investigation has become the default position without there being proper consideration as to whether that is necessary.

The biggest cost of all is the impact on patient care. Unnecessary disciplinary investigations and hearings risk creating an environment where the response to a mistake or sub-standard behaviour is not “how do we prevent it happening again” but “who is to blame.” The steep authority gradients in much of the NHS as a whole, and within individual occupations, exacerbate the problem. As Mary Rowe explained nearly two decades ago, when “the organisational culture is too hierarchical and oriented towards punishment (it) may inhibit willingness to act or come forward.” An environment of blame is toxic for patient care and safety.

None of this means that there will never be a need for NHS disciplinary investigations or indeed suspensions or sanctions. But in too many organisations moving to a formal investigation has become the default position without there being proper consideration as to whether that is necessary.

There is very significant variation between NHS Trusts as to the likelihood of staff being disciplined or suspended. We know it is several times more likely that staff will enter disciplinary investigations in some trusts compared to others. We also know from the NHS Workforce Race Equality Standard 2016 Data Analysis Report for NHS Trust that disciplinary action is much more likely for staff from a Black and Minority Ethnic (BME) staff background. Yet there is no evidence that greater levels of disciplinary investigation and action in healthcare lead to improved care.

So what can be done to get the balance right?

Surgeon stock image

Moving from blame to learning

Eighteen months ago I asked “Can a simple patient safety tool help the NHS end its ‘blame culture’?

I suggested that it was time to refresh the almost forgotten NHS Incident Decision Treeand combine the research evidence about the reasons for the disproportionate disciplining of BME staff in the NHS to create a new approach to tackling disciplinary action which would benefit all staff, organisations and patients.

The Incident Decision Tree was a by-product of Liam Donaldson’s landmark 2003 report ‘An organisation with a memory‘ It was a simple but sophisticated means of asking a series of structured questions about an individual involved in a patient safety incident with a view to deciding if suspension was appropriate.  The Incident Decision Tree uses very simple algorithm, to ask four sequential ‘tests’ when a patient safety incident occurred:

  1. Did the member of staff intend to cause harm?
  2. Did ill health or substance abuse cause or contribute to the patient safety incident?
  3. Were protocols and safe working practices adhered to?
  4. If protocols were not in place or were ineffective, how would someone from the same area of activity and possessing comparable qualifications and experience have been likely to deal with the situation?

The NPSA guidance then addressed the issue of whether to suspend staff when something goes wrong:

“We know from research carried out in the NHS and in other industries that systems failures are often the root cause of safety incidents. Despite this, where a serious patient safety incident occurs in the NHS, the most common response is to formally suspend the staff involved from duty and then deal with them according to disciplinary procedures. This route can be unfair to employees and divert managers from identifying contributory systems failures. Suspension of key employees can also diminish trusts‘ ability to provide high-quality patient care.”

Disproportionate disciplining of BME staff

In researching the causes of disproportionate disciplinary action in the NHS against BME staff, Archibong and Darr (2010) found in their report NHS Employers that

“….line managers found it difficult to deal with issues relating to disciplinaries and there were often inconsistencies in the application of disciplinary policies. It was acknowledged that the informal stage of the disciplinary process was critical in sorting out minor issues and that some managers were hindered in this process by a lack of confidence in applying informal strategies with BME staff. It was perceived that managers were more likely to discipline BME staff over insignificant matters and that disciplinary concerns involving staff from minority ethnic backgrounds were not always considered to have been dealt with fairly and equitably by human resources managers.”

“It was agreed that performance issues were not addressed in a timely fashion, often with a lack of effective feedback, performance appraisal, support and monitoring of progress with regard to BME staff. There was also a sense that line managers were incorrectly using a disciplinary policy to address performance issues. Part of the problem, it was perceived, stemmed from some managers not being equipped with the relevant skills and knowledge to be able to manage a diverse workforce and to deal effectively with conflict situations.”

Archibong and Darr highlighted the difficulty some managers had in conducting the same informal conversations with BME staff that they would have with white staff about their conduct, standard of work or mistakes. Some trusts have carried out root cause analyses of the differential treatment and have confirmed this is a significant problem. Some individual NHS trusts, in response to such evidence, have introduced a form of accountability which requires local managers to demonstrate that commencing a disciplinary investigation is really the appropriate step to take (for all cases not just those of BME staff).

How this is done varies between organisations, but all use what the HR Director for Barts Health calls a “triage” system to determine whether a proposed disciplinary investigation is really necessary or inappropriate. Increasingly those questions have been formalised into a checklist which combines Incident Decision Tree principles with what the research suggests is the particular challenge around BME disciplinary cases. I summarised this approach in the “what works” section (pp 110-143) of this year’s NHS workforce Race Equality Standard 2016 Data Analysis Report for NHS Trusts.

Once a disciplinary investigation commences, it is very distressing for the member of staff concerned even if they are cleared of any allegation.

There are other initiatives which can be helpful in removing the need for disciplinary investigations when the real problem is inadequate induction, supervision or support, especially for newly recruited nurses or staff trained overseas.

Finding fault

Once a disciplinary investigation commences, it is very distressing for the member of staff concerned even if they are cleared of any allegation; it is very time consuming for managers and HR; it can be demoralising for colleagues if they think the processes are unfair; and can run the risk of reinforcing blame, not a learning culture.  Investigations can easily lead to “tunnel vision”, where the determination to find fault will inevitably eventually unearth some shortcoming, as it would with any member of staff.

What the NHS organisations adopting this different approach have in common is

  • a determination to avoid, wherever possible, suspension and disciplinary action unless absolutely necessary and to prioritise learning how to prevent future shortcomings rather than individual blame
  • an acknowledgement that excessive disciplinary action may be taking place in respect of staff from all backgrounds and especially, unwittingly or otherwise, from BME backgrounds
  • accountability of decision makers, using data to check if change is underway
  • an emphasis on ensuring that, within induction, new staff (whatever their origins but especially if trained overseas) understand the trust values and are given support over time
  • early intervention by trained and committed senior staff to distinguish between blame and accountability is important, using a decision tree type approach.

NHS disciplinary processes do generally state their purpose is primarily to help improve the practice or behaviour of NHS staff, not to punish them. In practice this is not always the case. Too often the disciplinary process itself (including suspension) is an act of punishment whose focus and outcome is often not on learning and improvement, and which instead obscures systemic organisational failings in the name of holding individual staff to account. Disciplinary processes often confuse “accountability” and “blame”.

This different approach will not prevent the need, sometimes, for disciplinary investigations and sanctions. But early results suggest the use of a “triage” or “filter” to prompt reflection and challenge prior to any disciplinary investigation starting can make a very significant improvement to the prevailing practices in large parts of the NHS, to the benefit of staff, patient care and safety, and the organisation itself.

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World AIDS Day: fear, community and hope

Ant Babajee, CRM Manager and MSc Applied Public Health student at Middlesex University, reflects on how far we’ve come in the fight against HIV, and looks forward with renewed optimism towards a future without AIDS.

World AIDS Day is a time for reflection. This 1 December will be my 10th living with HIV, a virus that without treatment can damage the immune system and lead to AIDS.

I received my fateful phone call on 2 January 2007. It was a life-changing moment for me, but I was fortunate: effective combination therapy for HIV had been first introduced more than a decade earlier. I would have to find a way to live with this virus. Over time, and with the support of friends and my family, I grew in confidence and managed to cast off the shame and stigma so often associated with HIV.

As we near the end of the fourth decade of the HIV epidemic, how far have we moved on?

The power of fear

According to the World Health Organisation (WHO), since the beginning of the epidemic in the 1980s, about 35 million people have died from HIV-related illnesses.

I remember seeing the frightening tombstone and iceberg public health campaigns about AIDS as a child growing up in the 1980s.

There are few medical conditions that generate so much fear, stigma and misinformation as HIV and AIDS.

Writing in the programme for the recent critically acclaimed National Theatre revival of Tony Kushner’s Angels in America, Ian Green, Chief Executive of Terrence Higgins Trust (THT), says:

‘In those early days, panic spread as quickly as the virus, and the perceived ‘risks’ were everywhere: cups, towels, hugs and kisses, even communion wine.’

To be clear, HIV can’t transmitted in any of those ways.

Within the past fortnight, THT – along with the British HIV Association – felt compelled to issue a statement condemning Avon and Somerset Police for stating that their new so-called ‘spit hoods’ would protect their officers from HIV.

In the late 1980s, Princess Diana was pivotal in changing public attitudes towards people with HIV and AIDS. In front of the world’s media, she shook the hand of a man with AIDS without gloves, publicly challenging the notion that HIV was passed from person to person by touch. Her son Prince Harry has recently picked up the mantle and taken two HIV tests live on camera. His first official engagement with his bride-to-be, Meghan Markle, will be at a Terrence Higgins Trust centre in Nottingham this World AIDS Day.

The power of a symbol

Many charitable causes have a coloured ribbon associated with them. The red ribbon was the first such symbol, devised by a group of artists in New York in the early 1990s – a symbol of remembrance for those lost to AIDS and a symbol of solidarity with those living with HIV.

The colour red was chosen because of its ‘connection to blood and the idea of passion – not only anger, but love’, and a ribbon selected because it was easy to make and wear with a safety pin.

The power of community

In the 1980s, on both sides of the Atlantic, the LGBT+ community came together to care for those who were sick and to fight for effective medication. David France’s Oscar-nominated film and award-winning book, How to Survive a Plague, tell the story of ACT UP (the AIDS Coalition to Unleash Power) in the States.

As someone who professes to be an HIV campaigner, I know I stand on the shoulders of giants. If it hadn’t have been for groups like ACT UP, I do wonder whether I would be alive today – would we have such effective and life-saving treatment for HIV now? Would more people have died while those first antiretroviral drugs were still in development?

Meanwhile, on this side of the Atlantic, THT was set up in the memory of Terry Higgins – one of the first people to die from AIDS in Britain – by his partner and friends.

I owe a huge debt of gratitude to all of those ACT UP and Treatment Action Group (TAG) activists in the US, and to all of our home-grown activists here in the UK. They kept pushing and pushing for better treatments with fewer side-effects, and they helped care for and support those people who became sick.

Today, as people living with HIV, we still strive to support each other. I volunteer as a peer mentor for Positively UK’s Project 100, which aims to ensure 100 percent of people living with HIV across the UK have access to high-quality peer support.

The power of language

Today, AIDS has arguably started to slip out of the lexicon. Thankfully I have never had an AIDS diagnosis, and people working in the field now prefer the less stigmatising term: late-stage HIV. I was able to access effective, life-saving treatment before my immune system became damaged. I describe myself as living with HIV – with the emphasis very much on the ‘living’ – and as unashamedly positive. I am sometimes a ‘patient’, but I am certainly not a ‘sufferer’ or a ‘victim’.

There is still no cure for HIV, and people do still die from HIV-related illnesses. People who are diagnosed late, when their immune system has already been damaged by the virus, continue to have a more than 10-fold increased risk of dying in the year following their diagnosis. The fight is certainly not over, and HIV and AIDS activism is absolutely still relevant today.

The power of PrEP and TasP

Epidemiologist Leon Gordis states that ‘prevention and therapy are all too often are viewed as mutually exclusive activities’. He says that ‘prevention not only is integral to public health, but also is integral to clinical practice’ and gives the example of the US Food and Drug Administration (FDA) approving the use of the HIV treatment Truvada as PrEP in 2012 as showing the link between prevention and treatment.

PrEP, or pre-exposure prophylaxis, is such an exciting development in the fight against HIV, where HIV-negative people use medication to protect themselves against the virus. In a number of studies, including the PROUD study, it was shown to be 86 per cent effective – and in practice, to be close to 100 per cent effective if taken correctly.

For me, PrEP is the obverse side of the same coin as TasP (Treatment as Prevention). PrEP is a way for HIV-negative people to protect themselves with antiretrovirals; treatment as prevention and an undetectable viral load are a way for HIV-positive people to stay healthy and to protect others. Having an undetectable level of HIV in your blood has been dubbed #UequalsU [undetectable = untransmittable] by HIV activists around the world. For me, it is a hugely empowering message.

I first heard about the concept of people with an undetectable viral load not being able to pass on HIV with the so-called Swiss Statement back in 2008. I had been living with HIV for about a year at that point, but I had not started medication. I started a few years later in 2010 and became undetectable within a few months. Even though I wasn’t on medication and wasn’t able to – or recommended to – start, it was hugely reassuring to me that I wouldn’t be able to pass on the virus after I did.

Actually, the body of evidence around U=U has been growing for the past 20 years. When the results of the large, international PARTNER study were released, they were further proof of what I and many others already knew and were sure of. U=U has now gained the backing of the WHO, UNAIDS and the CDC (Centers for Disease Control and Prevention) in the US, as well as 400 organisations from 60 different countries.

I have the infographic above with those PARTNER study results saved in my phone, as I often have to show it to sceptical or ignorant people I meet. Zero transmissions between the partners in that study is the proof that people successfully on HIV treatment cannot pass on the virus.

Even some people who are long-term diagnosed with HIV still struggle with this game-changing information, such are the emotional scars from the pre-medication era. Sadly, there are still so many ignorant people who do not even know that we have extremely effective treatment for HIV, let alone knowing about undetectability.

The power of hope

The latest figures from Public Health England, published this November, show a dramatic decline in new HIV diagnoses among gay, bisexual and other men who have sex with men for the first time since the epidemic began more than 30 years ago (a 21 per cent decline – from 3,570 new diagnoses in 2015 to 2,810 in 2016).

Geographical trends of new HIV diagnoses among gay/bisexual men, 2007-2016

This decline was focussed on five central London clinics that delivered high levels of HIV testing, including frequent testing of men at high risk of contracting HIV, together with starting newly diagnosed men on treatment straight away. This ‘test and treat’ strategy has been successful in American cities such as San Francisco. One of those central London clinics is 56 Dean Street, which has a clarion call on its website: Let’s get HIV to Zero.

For the Angels in America programme, Ian Green writes:

“We have all the medical tools we need to end this epidemic for good, and to ensure those living with HIV can enjoy healthy and happy lives – but we will never get there until we end the stigma.”

How do we renew the fight against HIV and honour those who went before us? How do we continue to care for people living with the virus as they grow older, and ensure they do not feel excluded? How do we ensure everyone who would benefit from PrEP or TasP has equitable access? Could a future without AIDS be in sight? Now is the time for action.

I give my final words of hope to Prior Walter, one of the protagonists in Angels in America:

“This disease will be the end of many of us, but not nearly all, and the dead will be commemorated and will struggle on with the living, and we are not going away. We won’t die secret deaths anymore. The world only spins forward. We will be citizens. The time has come. Bye now. You are fabulous creatures, each and every one. And I bless you: More Life. The Great Work Begins.”

Ant Babajee will chair a panel discussion of people living with HIV at Middlesex University on 1 December 2017 to mark World AIDS Day

HIV facts:

  • HIV (Human Immunodeficiency Virus) attacks the immune system and weakens the body’s ability to fight diseases.
  • AIDS (Acquired Immune Deficiency Syndrome) can develop when HIV damages the immune system to such an extent that it can no longer fight off a range of often rare infections it would normally be able to cope with.
  • Latest figures estimate more than 100,000 people are living with HIV in the UK, and more than 5,000 people are diagnosed positive every year. Of these, one in seven are undiagnosed and do not know they have the virus.
  • Antiretroviral treatment lowers the amount of HIV in the blood to undetectable levels, which stops it from damaging the immune system, and means the virus cannot be passed on to other people.
  • There is still a great deal of stigma about HIV. Stigma is damaging as it prevents people from getting tested, from accessing treatment and from living a happy and healthy life.
  • The most common way HIV is transmitted is through sex without a condom.
  • You cannot get HIV through casual or day-to-day contact. It cannot be transmitted through kissing, spitting, or sharing a cup, plate or toilet seat.
Health & wellbeing

Researching the wellbeing of students

Professor Antonia Bifulco, Dr Stephen Nunn, Dr Ruth Spence, Deborah Rodriguez and Dr Lisa Kagan of the Centre for Abuse and Trauma Studies at Middlesex University have been using a novel online approach called CLEAR to investigate the mental health and wellbeing of degree students. Here Dr Lisa Kagan gives an overview of the research and its findings so far.

We wanted to understand more about student life events. Our ESRC-funded research project ‘Stress online’, led by Professor Antonia Bifulco, involved designing and testing an online platform called CLEAR (Computerised Life Events Assessment Record).  CLEAR is based on and mimics a widely used interview of life events. The reason for going online rather than using the traditional interview is that it is more private and less time consuming but more personal and detailed than a questionnaire.

CLEAR looks at many different life events which fall under the broad categories of lifestyle, health and relationships. Examples of a life event could be things that are milestones like starting university and graduating, to having your computer hacked, relationship break up, illness etc. Unlike conventional life events questionnaires which would give a generic score for a particular life event, CLEAR helps the participants to think about the surrounding context of the event. The participant is then asked to give a rating of how negative and how positive the event was on a scale of 1-5.  Personalised feedback is provided upon completion about their individual life events and psychological wellbeing.

What did we want to look at?

We also added in a variety of questionnaires looking at depression, wellbeing and health and had access to student’s grades. A final questionnaire we used measures something called attachment style, which looks at how we relate to others – either in a secure, trusting manner or in a more insecure way such as fearing rejection. We know from previous research that having an underlying insecure attachment and then experiencing a severe life event is related to depression. We wanted to see if our new measure would also show this. Over the past year we asked students as well as a previously depressed group and a control group take part in our study to see what CLEAR can tell us about this.

University students - Photo by NEC Corporation of America (Creative Commons 2.0)
Photo by NEC Corporation of America (Creative Commons 2.0)

Who took part?

Altogether 328 participants completed CLEAR, including 126 Middlesex students. Most were first year psychology students and the vast majority were female. Not surprisingly, almost a third of all student events in the last year were related to education.  Work, health and partner events were also common ones, and along with education events, were more likely to be ones that were rated as very negative. The average number of life events was 2 per student with the highest being 8!

What did we find?

What was interesting was that 35% of students reported feeling depressed at some point over the past year which was much higher than the midlife control group (8%). They also reported lower feelings of general wellbeing and unlike the midlife samples, positive events did not seem to make any difference to feelings of wellbeing. Consistent with our previous studies, students who filled out CLEAR who had an insecure attachment style and a very negative life event were more likely to experience feelings of depression.

With regards to student grades, those who achieved higher grades were less likely to have experienced feelings of depression, were more secure in their attachment and had not experienced traumatic events over the past year. Contrary to what we might have expected, experiencing general negative life events did not have an impact on grades.

What next?

Of particular interest and cause for concern is the general psychological wellbeing of students and how they can be supported in this time of life. Although most of the student sample were female first year psychology students, these levels of depression are consistent with media reports. We are hoping in the future that CLEAR will identify students who may be at risk for depression and other mental health issues due to ongoing life events. They can then be signposted to the appropriate services and receive the support they need.  We also hope it will help people have a better understanding of their stress and its impact on their health through the personalised feedback at the end.

We know anecdotally that some participants felt that the measure helped them to think about their experiences over the past year and how they dealt with them. We are still collecting data as part of a further study looking at student wellbeing. If you are a student interested in having a go at CLEAR please email us at and we will give you a personal login.

Health & wellbeing

Violence and women’s mental health

nicky-lambert-profileNicky Lambert, Associate Professor in Mental Health, examines the findings of a new review of research into connections between violence against women and mental health.

The article begins boldly with the statement: “Violence against women is widely recognised as a violation of human rights and a public health problem.”

This is a welcome message for those with an interest in women’s health, as the paper ‘Violence against women and mental health‘ calls for raised awareness around the impact of violence on the wellbeing of women.

Women’s mental and physical health has been compromised by an austerity agenda that has simultaneously reduced welfare support and cut funding to organisations from refuges to women’s centres, and whilst gender specific violence is an established public health concern, some practitioners still see it as a personal problem and are uncomfortable with the idea that it falls within their practice remit.


The authors formulated this review by searching MEDLINE, Embase, and PsycINFO for English language primary studies and reviews reporting on mental health service responses to domestic violence and other forms of violence against women between Jan 1, 2009, to Jan 12, 2016. The search terms for violence against women were generated from terms published in relevant Cochrane protocols and additional papers were found by citation tracking using Web of Science, Google Scholar, and personal files.

So how widespread is this issue?

The authors refer to World Health Organisation data indicating that 35% of women worldwide have experienced intimate partner violence or non-partner sexual violence (WHO, 2013). For England, they use the 2013–14 Crime Survey (the most current data) which found that 2·2% of women aged 16–59 years had experienced some form of sexual assault; that is approximately 355,000 women and that 8.5% had experienced domestic abuse in the past year, which translates to approximately 1.5 million women.

The literature overview indicates that the main categories of violence against women in the research are:

  • Domestic violence and abuse
  • Sexual violence.

The authors explore the impact these forms of violence have on women’s mental health. They also identify other forms of violence against women and the consequences for mental health; including human trafficking and female genital mutilation (FGM).

Factors increasingly risk of being exposed to violence includes:

  • Young age
  • Disability
  • Poverty
  • Witnessing domestic violence and abuse in childhood
  • Childhood sexual abuse
  • Substance misuse.

What are the impacts of violence on women’s mental health?

The researchers refer to a systematic review and meta-analysis (Trevillion et al, 2012), which found that women who experienced domestic violence were three times more likely to have depressive disordershad a four times increase in the likelihood of anxiety disorders and a seven times increase in the likelihood of post-traumatic stress disorder.

The paper also notes the high prevalence of experience of violence amongst women who are court-involved, using secondary mental health services, Increasing Access to Psychological Therapies (IAPT), GP’s surgeries and those who present with complex care needs. It also highlights a failure of practitioners to recognise abuse because of a focus on psychiatric symptoms rather than on the service user’s experiences.

This tendency was also highlighted in work by Williams and Paul (2008) which found that services can fail to meet the needs of women by asking ‘what’s wrong with this woman?’ which locates the problem within the individual rather than ‘what’s happened to this woman’ which looks at the impact of her life experiences on her health.

It is frustrating to see half of the population still so poorly served as it has been many years since Dr. Marianne Legato highlighted the impact of gender on health by critiquing the traditional and reductionist approach to women’s wellbeing nicknamed “Bikini Medicine”. Bikini Medicine is the focus on breasts and reproductive health (areas covered by a bikini) and assuming it provides an acceptable level of holistic healthcare to women. Gender-specific health takes into consideration how biology differs between men and women and how that affects research, diagnosis and treatment of disease. It also provides a starting point to explore how factors outside the biomedical sphere, such as violence also shape women’s wellbeing.

What are the implications for practitioners?

This paper presents evidence that many people working in health services are not clear about their role in tackling gendered violence. The authors summarise the debate around universal screening in generic services and note that Routine Inquiry is an expectation within mental health services; and they go on to highlight the specific training and emotional support needs that result.

What are the implications for researchers?

This paper highlights the importance of considering gender within research so that findings can be relevant to both men and women. In particular the authors make a plea that gendered risk factors such as intimate partner violence are included in studies of the epidemiology or treatment of mental disorders.

They also ask that barriers to participation are addressed, including those stemming from practical considerations such as caring responsibilities to those raised by ethical concerns such as teratogenic risks.

Strengths and limitations

This paper provides a much needed summary of the current evidence base around violence against women and its impact on their mental health. It usefully defines concepts and clarifies terminology, it takes an open and straightforward approach to complex issues including the abuse of trafficked women and FGM and it offers an overview of the risk factors for being exposed to gendered violence.

It also highlights some of the confounding factors that can obscure pertinent data, notably the fact that women’s experiences of ongoing violence can be obscured by the ‘capping’ of reports of repeat victimisation in crime surveys.

This paper succeeds in providing an overview of the issue of violence against women and mental distress; however it has such a wide remit that it skirts issues of intersectionality, which limits depth of understanding in regards to this phenomenon. It is also important to note that there are skeptics of the strategy of conceptualising social and political problems as health issues. There are concerns that medicalising social ills such as poverty, crime, and marginalisation may prevent them from being tackled by more appropriate bodies.

Another point to consider is that whilst we are seeing a groundswell of interest in this topic, there are still limited numbers of robust studies addressing this widespread public health concern. This means any review at this point has limited data to draw on and can only be initial remarks rather than the last word on the subject!


The authors conclude that little research has been done to improve identification and treatment of victims and perpetrators in contact with mental health services, but that mental health services could play a major role in primary and secondary prevention of violence against women. The review makes clear links between violence against women and poor mental health and it concludes that all mental health services should be acting to identify violence against women, prevent further violence, and treating the mental health consequences more effectively, Congratulations to the Lancet for taking a lead on such an important and relevant practice concern. 

Violence against women is linked to higher levels of mental distress and mental health workers should support the wellbeing of the women they encounter by considering gender and trauma-informed ways of working within their everyday practice.

This study adds to the increasing amount of evidence emerging from the voluntary sector that social and political factors such as gender specific violence negatively impact women’s health. From the Girls Attitude Survey (Girlguiding, 2016) in which girls as young as 7 years old spoke in their own words about the impact of sexism on their sense of wellbeing; to the Joining the Dots report by Agenda (2016) which explores the effect of multiple exclusions using data from the latest Adult Psychiatric Morbidity Survey (APMS).

Joining the Dots is an interesting companion piece to this article as it examines the nature and extent of violence and abuse experienced by women in poverty, and the ways these issues impact on individuals and can amplify negative health outcomes. It also expands on the social determinants of risk of violence and ill health and explores how multiple exclusions can be interrelated and reinforce each other.

This article was originally published on the National Elf Service blog.


Health & wellbeing

The sickness label

Sarah Carr Middlesex UniversityAssociate Professor of Mental Health Research, Dr Sarah Carr, is currently involved in a research project to survey lesbian, gay, bisexual and transgender inclusion in higher education institutions’ health and social care curricula, with colleagues Alfonso Pezzella and Professor Trish Hafford-Letchfield.

As part of the LGBT History Month activities taking part at Middlesex University in February 2016, she details the long struggle to change the classification of homosexuality as a mental illness over nearly half a century.

For LGBT History Month 2016, it’s important to look back on the impact early lesbian, gay and bisexual activists and ancestors had on the world. One crucial contribution was to contest the psychiatric diagnosis and pathologisation of homosexuality.

Almost 50 years ago, in the wake of the Stonewall riots that marked the beginning of the gay liberation movement in the US, a group of radical British gay men and women were creating the Gay Liberation Front. Later, a direct challenge to psychiatry formed a key part of their 1971 manifesto: “One way of oppressing people and preventing them getting too angry about it is to convince them, and everyone else, that they are sick. There has hence arisen a body of psychiatric ‘theory’ and ‘therapy’ to deal with the problems and ‘treatment’ of homosexuality.”

At the time, homosexuality was classified as a mental illness. As the gay liberation movement grew in the US and Britain, activists campaigned tirelessly to remove homosexuality as a disease classification and as a mental disorder from diagnostic manuals.

Gay Pride Toulouse - Photo by Guillaume Paumier (Creative Commons 2.0)
Photo by Guillaume Paumier (Creative Commons 2.0)

The sickness label

The sickness label was used by a psychiatric system that strived to ‘cure’ gay people and to discredit lesbian and gay civil rights activists. In 2005, Barbara Gittings, one of the original campaigners in the US, recalled the oppressive power of psychiatry: “The sickness label infected everything we said and made it difficult to gain credibility for ourselves. The sickness label was paramount.”

Thanks to these pioneering activists, in 1973 the American Psychiatric Association finally recognised that being gay did not mean being ‘mentally ill’ and homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders. However, the option to diagnose someone with ‘sexual disorder not otherwise specified’ remained until 1994. Homosexuality as a mental illness itself was only finally removed from the World Health Organization International Classification of Diseases (ICD-10) in 1990 – incidentally, the same year a therapist was attempting to cure me of my ‘illness’.

Sadly, changes on paper do not always mean changes in mental health practice. Research in 2009 showed that 17 per cent of the 1,400 therapists surveyed had attempted to help patients reduce feelings of same-sex attraction. Findings from a 2015 study of risk and resilience in LGB and T mental health, with more than 2,000 people, showed that “participants reported that a lack of awareness and training means responses from medical or professional staff can feel inadequate. Inclusive resources, which reflect the lives and issues of young LGB and T people, are sparse outside of LGBT+ specialist services”.

The pathologisation legacy remains influential in mental health services, often making them inaccessible, oppressive or even unsafe for lesbian and gay people, or for people who are unsure about their sexual orientation. My research has shown that the lesbian and gay community may be suspicious of mainstream mental health services and many may choose not to engage with them when they are in distress.

Alan Turing aged 16
Alan Turing

Coming out alive

In 1999, Michael King and Annie Bartlett, researchers who explored gay people’s experiences of UK mental health services, concluded that “the conservative bias inherent in psychiatry and psychology has damaged the lives of gay men and lesbians and provided grounds for discrimination”.

When you know what went on in some NHS psychiatric hospitals until the 1970s you can understand what they meant: lobotomies, hormone treatment, chemical castration, electric shock and emetic aversion therapy. Anyone familiar with the life and death of Alan Turing will know that in 1952, he was charged with indecency when being gay was still illegal for men, and chose probation with hormone treatment instead of imprisonment.

Peter Price was a gay man who psychiatrists attempted to ‘cure’ with aversion therapy in the 1960s, using emetic drugs to make him sick when he was shown sexual images of men. His horrific ordeal is recounted in my 2010 article, ‘The Sickness Label’.

“For seventy-two hours I was injected, I drank, I was sick… I just had to sit in my own vomit and excrement… I was in a terrible state. What was going through my mind was not the fear of being gay; it was the fear of not coming out of the psychiatric wing alive.”

Fortunately, Peter did come out alive, but Mathew, a young gay man sent to a military hospital instead of the prison for having a sexual relationship with a man, did not. As his sister Colleen found out years later, Mathew had been given the emetic drug apomorphine and had died as a result.

“What he’d ended up dying of was dehydration and that had brought on a massive stroke,” she told me. “It’s what people die of in countries without much water when they’ve got diarrhoea and vomiting; it’s really bad care, why someone in the UK should actually die because of just vomiting.”

Or indeed because he loved men.

Guillaume Paumier (Creative Commons 2.0) (2)
Photo by Guillaume Paumier (Creative Commons 2.0)

Refusing to play the game

“The plague of mankind is the fear and rejection of diversity… The belief that there is only one right way to live,” wrote the famous ‘anti-psychiatry’ psychiatrist Thomas Szasz in a 1973 critique of his own profession.

Unfortunately, some mental health services are still in the business of making sure people ‘play the game’, with certain therapists exploiting gay people’s internal conflicts about their sexual orientation (and sometimes faith), confusion about identity, or distress at rejection and discrimination, in order to make them ‘normal’. GPs are still sending gay people like me who experience mental distress for conversion therapy.

The exposure of the continued practice of forms of aversion therapy in mental health services prompted the British Medical Association to vote that the NHS should not fund ‘discredited’ and ‘harmful’ conversion therapy. Speaking for the motion, junior doctor Tom Dolphin said: “Sexual orientation is such a fundamental part of who someone is that to attempt to change it will just result in significant conflict and depression, and even sometimes suicide.”

Despite the fact that the World Health Organization ICD-10 removed homosexuality as a disorder in itself, it nonetheless contains contains five ‘F66’ disorder categories relating to sexual orientation and gender identity.

We need to keep questioning and challenging psychiatric theories about lesbian, gay, bisexual and transgender people

A recent review of these categories for the forthcoming ICD-11 in 2018 concluded that “from a human rights perspective, the F66 categories selectively target individuals with gender nonconformity or a same-sex orientation without apparent justification”.

Perhaps then, the last word should come from the 1971 Gay Liberation Front manifesto, as it still holds true today:

“That psychiatrists command such credence and such income is surprising if we remember the hysterical disagreements of theory and practice in their field, and the fact that in formulating their opinions, they rarely consult gay people. In fact, so far as is possible, they avoid talking to them at all, because they know that such confrontation would wreck their theories.”

We need to keep questioning and challenging psychiatric theories about lesbian, gay, bisexual and transgender people, because those theories can still lead to the broken minds and lives of many across the globe today.

Health & wellbeing

The social impact of authoritative parenting

Lynn McDonald Middlesex UniversityProfessor Lynn McDonald is the founder of Families and Schools Together (FAST), a multi-family group programme designed to increase child well-being and build cohesion within low-income and socially marginalised families. She responds to the recent government pledge to increase relationship support for families to help prevent poverty.

In a recent speech on his Life Chances Strategy, David Cameron outlined how the government intends to transform the lives of Britain’s poor. Emphasising the importance of strengthening families in helping to prevent poverty, he pledged to take action against poor parenting and announced a doubling of funding for relationship support over the next five years.

“Families are the best anti-poverty measure ever invented,” Mr Cameron said. “They are a welfare, education and counselling system all wrapped up into one.”

Solid structures

As the founder of early intervention programme Families and Schools Together (FAST), I support David Cameron’s initiative to make evidence-based and supportive parenting groups available to everyone. Modern societies should provide solid structures to support the challenge of parenting a child into adulthood, rather than leaving them on their own to manage.

Cameron’s comments sparked renewed debate about the wider social impact of parenting– particularly in a comment piece in the Observer, which referenced a parenting typology developed by psychologist Diana Baumrind. In the early 1960s, Baumrind began conducting research which led to the identification of four parenting styles – authoritarian, authoritative, permissive and uninvolved – which impact child development outcomes.

Modern societies should provide solid structures to support the challenge of parenting a child into adulthood.

Authoritative parenting

According to Baumrind’s typology ‘authoritative’ is the best of the four types of parenting, combining authority and warmth. With this as my basis, I developed a parent-child relationship self-assessment scale with questions on authority and warmth to produce an overall score. This scale is a key component of FAST, a programme bringing together parents, children, teachers and the wider community in order to strengthen relationships and make sure children get the support they need to fulfil their potential at school.

FAST expresses the traditional notion that it takes a village to raise a child.  The multi-family group is open to everyone and gathers between 20 and 40 whole families for sessions at a local school. The activities are led by parents and focus on strengthening the parent-child relationship, the family as a unit, the parents’ social networks as well as the parent-school relationship.

Parents reported feeling more efficacious and having a stronger parent-child bond

FAST is having a positive impact. As well as showing a significant impact on education performance, parents reported feeling more efficacious, having a stronger parent-child bond, having reduced family conflict, increased social support for parents, and a higher parent involvement in school and community.

The scale I developed has assessed 9,500 parents in the UK before and after an eight-week multi-family parenting programme since 2010, with results demonstrating a statistically significant improvement in authoritative parenting after the programme.