Editors Picks Health & wellbeing

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

Business & economics

How can we end the NHS ‘blame culture’?

Roger Kline Middlesex UniversityWhen things go wrong in the workplace, it is all too easy to lay the blame on individual members of staff.

Roger Kline, a Research Fellow in the Business School at Middlesex University, the author of ‘Discrimination by Appointment’ (2013) and ‘The Snowy White Peaks of the NHS’ (2014), explains how a four-step questionnaire could help the NHS avoid unnecessary suspensions and instead shift the focus onto tackling organisational problems.

The data on NHS disciplinary proceedings shows it is twice as likely that black and minority ethnic (BME) staff will enter the disciplinary process as white staff.

A recent authoritative analysis of grievance and disciplinary procedures concluded there was “no evidence” that the standard NHS HR reliance on policy, procedure and training allied to the ACAS Code of Practice “had a moderating effect on the outcomes of individual employment disputes. In fact adherence to the key principles was associated with higher rates of disciplinary sanctions”. Remarkably, “more positive employer attitudes in respect of employment relations and fairness were found in workplaces in which the key principles were not adhered to”.

Might a tool developed to tackle patient safety incidents be one way of addressing these concerns? Some NHS Trusts think it might be.

phonendoscope in doctor arm

The Incident Decision Tree

The publication 15 years ago of Liam Donaldson’s ‘An organisation with a memory‘ was a landmark event in patient safety. The report was a review of the scale and nature of serious failures in the NHS, examining its capacity to learn from them, and recommending measures to minimise repeated cases. It drew on evidence from sectors outside health, including the aviation industry. It revealed that “the NHS had no systematic way of identifying, learning from and dealing with things that went wrong”. The report concluded that “without any organisational memory, history is doomed to repeat itself: the error that causes a bad experience for one patient would never prevent future patients from being harmed”.

One excellent by-product of the 2001 report was the development by the National Patient Safety Authority (NPSA) of the Incident Decision Tree. The Incident Decision Tree was a simple but sophisticated means of asking a series of structured questions about an individual’s actions, motives and behaviour at the time of a patient safety incident. Remarkably, significant numbers of those who should be applying its approach in the NHS today have never heard of it.

The Incident Decision Tree uses a flowchart to ask four sequential ‘tests’ when a patient safety incident occurs:

  1. Did the member of staff intend to cause harm?

The deliberate harm test helps to identify at the earliest possible stage those rare cases where harm was intended. If the answer to this question is no, then we should ask:

  1. Did ill health or substance abuse cause or contribute to the patient safety incident?

Managers are asked to consider whether the staff member was aware of their condition at the time, whether they realised the implications of their condition, and whether they took proper safeguards to protect patients. If the answer to this question is no, then we should ask:

  1. Were protocols and safe working practices adhered to?

Many patient safety incidents involve protocol violation and this is the most complex question. Managers are asked to consider whether the incident arose because:

  • No protocol or safe procedure existed.
  • The protocol was poor.
  • There were conflicting protocols.
  • Good protocols were misapplied, routinely violated, or not in regular use.
  • The individual decided to ignore protocols.

Managers are asked to note that what at first sight appears to be a workable protocol may be not be so straightforward. If a sound protocol was violated, the manager is advised to consider factors such as why a violation occurred, the speed with which a decision had to be reached, and so on. If the answer to this question is no, then we should ask:

  1. 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?

This test might point to deficiencies in training, experience, or supervision. Managers are specifically advised to avoid reliance on behavioural norms and stereotypes.

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

“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. The Incident Decision Tree has been developed to help managers:

  • decide whether it is necessary to suspend staff from duty following a patient safety incident;
  • explore alternatives to suspension, such as temporary relocation or modification to duties; and
  • consider other measures that might need to be taken as the investigation into the incident progresses.

Although individual accountability is in no way diminished by this approach, it helps trusts focus on the ‘what’ and ‘why’ rather than the ‘who’. In 2001 a joint declaration by the government and the medical profession called for the NHS to be more open in the way it deals with professional mistakes and to ‘recognise that honest failure should not be responded to primarily by blame and retribution but by learning and a drive to reduce future risk to patients’.”

Surgeon stock image

Ending the ‘blame culture’

A small number of NHS Trusts are trying to find ways to adapt this approach to wider disciplinary issues. A culture of learning from mistakes, poor conduct, or poor behaviour is likely to be more productive than knee-jerk disciplinary action. That is not to say disciplinary action or suspension will never be necessary. They will be. But the Incident Decision Tree might be a really good way of determining whether we have the balance right.

It is a challenge to a blame culture which can lead too easily to suspension and in which staff who are ‘different’ may be more vulnerable to blame. Its adoption to some (indeed many) potential disciplinary cases would require reflection prior to any decision to commence disciplinary proceedings. So, it requires a senior manager familiar with the principles to apply the approach to any proposal to commence disciplinary proceedings. It would encourage other approaches which might be more beneficial for patients, the organisation and the member of staff.  It would lead to greater use of Root Cause Analysis so that systems failings can be identified and with an emphasis on learning not blame.

The NHS accepts it must move away from a blame culture. Adopting the Incident Decision Tree approach to some (many) potential disciplinary cases might just be one way of improving NHS cultures, reducing suspensions, and helping organisations reflect on inappropriate and discriminatory disciplinary decisions.

Business & economics

Has NHS patient safety culture improved since Mid Staffordshire?

Roger Kline Middlesex UniversityRoger Kline is a Research Fellow in the Business School at Middlesex University, the author of ‘Discrimination by Appointment’ (2013) and ‘The Snowy White Peaks of the NHS’ (2014), and was closely involved in the development of the NHS Workforce Race Equality Standard.

In the week when the first-ever national NHS Whistleblowing Policy was launched, he looks at what NHS staff surveys say about progress towards a culture conducive to patient safety three years on from the publication of the final Mid Staffordshire public inquiry report.

The NHS Constitution (Clause 3b) states:

“There is an expectation that NHS staff will raise concerns about safety, malpractice or wrongdoing at work which may affect patients, the public, other staff, or the organisation itself as early as possible.”

Ministers have launched a number of initiatives, partly in response to the Public Inquiry report into Mid Staffordshire NHS Foundation Trust intended to improve patient safety. However, several reports, including from Parliamentary Select Committees, the Sir Robert Francis ‘Freedom to Speak Up‘ review and NHS Staff Survey data, suggest that if improvement is under way it may be glacial.

Hospital corridor and doctor as a blurred defocused background


NHS Staff Survey data 2010-2015

The NHS Staff Survey analyses responses from about 300,000 NHS staff. It is the most authoritative analysis of staff opinion. It asks a number of questions directly linked to patient safety:

  • “My trust treats staff who are involved in an error, near miss, or incident fairly.”

There has been an increase in the proportion of staff agreeing (42 per cent to 43 per cent) and an increase in proportion of staff disagreeing with this statement (from five per cent to nine per cent).

  • “My trust encourages us to report errors, near misses, or incidents.”

An improvement in the proportion of staff agreeing with this statement (from 81 per cent to 85 per cent).

  • “My trust blames or punishes people who are involved in errors, near misses, or incidents.”

The proportion agreeing with this statement rose from nine per cent to 11 per cent, as did the proportion disagreeing with the statement (from 39 per cent to 45 per cent). This question was not asked in 2015.

  • “When errors, near misses, or incidents are reported, my trust takes action to ensure that they do not happen again.”

The proportion agreeing with this statement rose from 55 per cent to 62 per cent, as did the proportion disagreeing with the statement (from five per cent to seven per cent)

  • “We are given feedback about changes made in response to reported errors, near misses and incidents.”

The proportion agreeing with this statement rose from 35 per cent to 50 per cent while the proportion disagreeing with the statement fell (from 25 per cent to 17 per cent). A very clear improvement.

  • “Would you feel safe raising your concern?”

The proportion saying they felt safe raising their concerns fell from 72 per cent to 68 per cent between 2012 and 2015 while the proportion saying they did not feel safe rose slightly from ten per cent to 11 per cent. This question was not asked in 2010-11. Comparisons based on these responses should be treated with great caution as the question was changed in 2014 to “I would feel secure raising concerns about unsafe clinical practice”.

  • “Would you feel confident that your organisation would address your concern?”

The proportion agreeing with this statement rose from 55 per cent to 56 per cent, while the proportion disagreeing fell from 13 per cent to 12 per cent. This is statistically not significant.

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


On two of the Staff Survey questions there is clear improvement, most clearly on whether staff are given feedback about changes made in response to reported errors, near misses and incidents. On four of the questions there is both a slight improvement and a deterioration in staff views.

The adverse impact of bullying on the willingness of staff to raise concerns or admit mistakes (and work in effective teams) is an established factor in patient safety culture. Bullying of NHS staff by colleagues and managers has increased in recent years from 14 per cent (2010) to 23 per cent (2015), while the NHS Staff Survey records that the actual reporting by staff of incidents of bullying has fallen significantly from 54 per cent to 42 per cent in the last decade i.e. staff are less willing to report bullying as bullying levels have risen. The evidence of the ‘Freedom to Speak Up’ review suggests a major challenge remains to enable those staff who do raise concerns that it is safe to do so (see Fig. 1).

Figure 1: A comparison of responses given by white NHS staff members to those given by black and minority ethnic (BME) members of NHS staff regarding whistleblowing 

Question White staff % BME staff %
I was satisfied with the response to my concern about suspected wrongdoing 41 27
I was victimised by management after raising a concern 13 21
I was praised by management after raising a concern 7 3
I am less likely to report a concern again if I suspect wrongdoing 59 73

Slow progress

No step change in patient safety culture of the scale demanded by Sir Robert Francis and ministers appears to have yet taken place. There is evidence of significant improvement in whether staff are given feedback when they raise concerns, but otherwise the data suggests slow progress at best, with some evidence of deterioration.

West and Dawson (2012) link the raising of concerns and whistleblowing to staff engagement, demonstrating that “engaged staff are more likely to intervene to raise concerns about safety or address poor behaviours”. Whether the pattern of simultaneous improvement and regression that the NHS Staff survey data demonstrates parallels the findings on staff engagement reported by the Kings Fund of a growing gap between the better Trusts and the majority of Trusts, may be worthy of further exploration.