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World Mental Health Day: How to make positive changes to your wellbeing

Nicky Lambert, an expert on mental health, reveals how people can take several simple steps to improve their personal self-care

It is World Mental Health Day on Tuesday 10 October. This year’s theme – set by the World Foundation of Mental Health – has been called ‘mental health is a universal human right’.  

It is a day that reminds all of us to make positive changes to increase our wellbeing and to raise awareness of mental health issues more broadly.

Pressures related to the ongoing fallout from the pandemic and cost of living crisis continue to impact mental health.

According to the World Health Organization (2020) more than 264 million people experience depression globally and it is the leading cause of disability. In addition to rising numbers of people with mental health problems, there are ongoing staffing and funding shortages and despite nurses’ best efforts mental health service provision can be limited, with long wait times.

Whilst there have been significant strides forward in public understanding of mental wellbeing, the stigma around many mental health conditions remains and can form a barrier to people seeking support and reaching out to help others. It’s important that we are all aware of the indicators of when we need help and that we know how best to support our own psychological wellbeing.

Raising awareness

Signs that professional help may be needed include:

  • Feeling constantly overwhelmed and unable to cope or see a way forward.
  • Significant personality changes or an increase in agitation, anger, anxiety or other mood changes.
  • Withdrawal or isolation from others, poor self-care.
  • Talking and thinking a lot about suicide or feeling you can’t go on
  • Or uncharacteristic engagement in risk-seeking behaviour

If you or someone you know needs help – which can range from a supportive conversation and counselling through to more formal care, please tell someone. There are university systems (Counselling and Mental Health – CMH) that are designed to help and offer guidance on emotional wellbeing and mental health. Please come forward when you first notice something amiss and don’t wait for a crisis before reaching out.

Promoting self-care

There are some misconceptions about self-care that we should address before looking at ways to support wellbeing. It is not indulgent or a luxury to look after our mental health – in the same ways that we have to be mindful of our physical health the same is true of our emotional and psychological wellbeing. Also, there is no right way to do it. Everyone is individual in their needs and what they find nurturing, however there are aspects of our lives that can offer us prompts to action:

Mental aspects of self-care – Set realistic goals and priorities and learn to say no without feeling guilty – boundaries help you place your energy where it is most needed.

Physical aspects of self-care – Move more! Just 30 minutes of walking every day can help boost your mood and improve your health. If it’s raining find somewhere you can be free to be by yourself and dance like no one is watching to your three favourite songs!

Environmental aspects of self-care – Spend some time outdoors every day, develop an awareness of nature, grow something at home – it can be anything from a house plant or herbs to liven up a meal.

Spiritual aspects of self-care – Reassess your purpose in life, think about what makes you happy and try to align yourself better to your goals. It may take time to make changes (if they are needed), but it is important to live a life that is meaningful to you and to identify things that you are feel grateful for.

Recreational aspects of self-care – Being creative takes many forms, perhaps you are a great cook, or you love making music or gardening. We can forget to play sometimes and remembering to prioritise times when we experience joy and the calm focus of being in a state of ‘flow’ is essential to our wellbeing.

Social aspects of self-care – Many bonds linking us have been placed under strain over the last few years. Even if you are at a distance from the people you care about, a regular zoom call with old friends or sharing a WhatsApp group with family or a local community keeps us stay connected.

About the author

Nicky Lambert

Nicky is an Associate Professor at Middlesex University, she is registered as a Specialist Practitioner (NMC) and is a Senior Teaching Fellow (SFHEA). She is also a co-director of the Centre for Coproduction in Mental Health and Social Care. Nicky has worked across a range of mental health services both in the UK and internationally supporting staff and practice development in acute and mental health trusts, councils, businesses, charities, HEE and the CQC. She is active in supporting mental health and wellbeing with the RCN and Unite. She is an editorial board member for Mental Health Nursing, and on the education and policy committees of MHNAUK. Nicky engages with local trusts and with the RCPsych to support sexual safety in mental health services. She is also a Trustee for The Bridge a charity supporting women to make positive choices, and encouraging improvements to fitness, health & well-being.

Twitter: @niadla

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Zero tolerance for bullying in healthcare?

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

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

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

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

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

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

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

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

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

The review added such an approach

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

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

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

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

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

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

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

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

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

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

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

Reitz then argues

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

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

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

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

Roger Kline is Research Fellow at Middlesex University Business School

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Racism which impacts healthcare staff endangers patient care

Nurse Efe Obiakur, who says she has long faced discrimination and harassment working in the NHS. Credit: Matt Brealey/CNN

As well as a moral issue, tackling racism affecting NHS staff is a crucial part of improving patient safety and care, says MDX Research Fellow Roger Kline

There is finally a growing awareness of the impact of discrimination on Black and Minority Ethnic patients.

There is equally a growing awareness of the scale of race discrimination in all aspects of the lives of citizens of Black and Minority Ethnic heritage including the quarter of a million Black and Minority Ethnic staff working in the NHS.

Not so well known is the impact of race discrimination against health and social care staff on the care and safety of all patients and service users.

We have a wealth of data demonstrating that BME staff in health care are disadvantaged in recruitment and career progression, in whether staff are disciplined, bullied and harassed at work, and are treated worse if they raise concerns or admit mistakes.

Such treatment demoralises staff, wastes talent, affects turnover, costs money, and damages staff health. But crucially it also undermines team working, incentivises blame, not learning, and adversely impacts patient health and safety.

Risk one: There is a serious risk that recruitment and promotion data means that selection panels may be choosing “people like us” or who can best “fit in” rather than the best candidates, thus depriving patients of the best possible talent.

The NHS has an ethnicity gradient in which the more senior the post the less likely we are to see BME staff. It is still 1.61 times more likely that a White shortlisted candidate will be appointed compared to a Black and Minority Ethnic shortlisted candidate. It is not surprising therefore that it is twice as likely that BME staff do not believe there are equal opportunities for promotion and career progression.

Risk two: A culture of blame not learning is a risk to patient care and safety

NHS BME staff are more likely than White staff to be disciplined. They are more likely to be reported to their professional regulator by their employer (though interestingly, not by the public). BME staff are more likely to be bullied by managers and colleagues than White staff and are three times more likely to report being discriminated against than their White colleagues.

Literature demonstrates the risk of racial bias in investigations. In combination, such treatment means it is more likely that the mistakes we all make are seen through the lens of blame, not learning for BME staff, not least because of the difficulty some White managers have in having honest conversations with BME staff.

Risk three: Racialised patterns of work are a risk to staff health and adverse impact on staff health may have consequences for staffing absence, discretionary effort and staff turnover, any of which may impact on patient care and safety, especially at a time of pre-existing staff shortages

Racialised patterns of employment were highlighted during Covid. According to Public Health England researchers, almost 90% of staff infection was due to occupational exposure. BME staff were disproportionately impacted because:  

  • They work disproportionately in lower-graded patient facing roles
  • They had poorer access to appropriate PPE with the correct fit 
  • They were more reluctant to raise concerns 
  • They were disproportionately redeployed to riskier areas
  • Agency staff (more likely to be BME) may not have been reimbursed when self-isolating or had poorer access to PPE.

More generally, we know that race discrimination makes people ill. Two decades ago, in journal article Agency and structure: the impact of ethnic identity and racism on the health of ethnic minority people, Nazroo and Karlsen found that:

“Over and above socioeconomic effects, both experience of racial harassment and perceptions of racial discrimination make an independent contribution to health. For example, those who had been verbally harassed had a 50 per cent greater odds of reporting fair or poor health compared with those who reported no harassment”.

Race discrimination is positively associated with an extensive range of adverse conditions including coronary artery calcification, high blood pressure, lower birth weight, cognitive impairment, and mortality. Moreover, discrimination, like other stressors, can affect health through both actual exposure and the threat of exposure. 

Risk four: If BME staff are more likely to be bullied that will impact on their health and their working lives as well, placing patient care and safety at risk

BME staff are 21% of the NHS workforce. An astonishing 28% of them reported being bullied and harassed by managers and staff last year, significantly more than White staff reported themselves as being (23%).

The adverse impact of bullying on staff health has been well evidenced by Lever and others and in turn impacts on performance, career progression, engagement, retention and team effectiveness, as well as harming the safety and physical and mental well-being of staff.

American medic Lucien Leape describes how a culture of disrespect in medicine is a threat to patient safety because ”it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale and inhibits compliance with and implementation of new practices”. Staff who are bullied are less likely to admit mistakes, raise concerns or work effectively in teams – all with consequences for patient care and safety.

Risk five: If staff are less likely to speak out and raise concerns that is likely to directly impact on patient care and safety

Robert Francis’ Speaking Up report (2015) drew on a survey of 20,000 NHS staff which found very significant differences between the experiences of White and BME staff who raised concerns.

It was 50% more likely that:

  • BME staff raising concerns would be satisfied with the response to their concern about suspected wrongdoing
  • BME staff felt they would be victimised by management after raising a concern
  • BME staff felt they had been victimised by co-workers after raising a concern
  • BME staff were 23% less likely than White staff to report a concern again if the staff suspected wrongdoing 
  • BME staff were 70% less likely than White staff to raise a concern about suspected wrongdoing, due to a fear of victimisation.

The NHS National staff survey 2020 reported a significant difference between White and BME staff views on raising concerns. It reported that staff from BME backgrounds are less likely (62.1%) to feel safe to speak up about any concerns than White staff (67.0%).

Risk six. Where staff of Black and Minority Ethnic heritage are not welcomed, their difference valued, and it is not a safe place for them to raise concerns, then patient care is likely to lose the benefit that improved representation can give.

Dawson (2009) found that

“the experience of black and minority ethnic (BME) NHS staff was a good barometer of the climate of respect and care for all within the NHS. Put simply, if BME staff feel engaged, motivated, valued and part of a team with a sense of belonging, patients were more likely to be satisfied with the service they received”.

Similarly West, M et al (2018) found that

“the % staff believing Trust provides equal opportunities for career progression or promotion… was a very important predictor of patient satisfaction in all three analyses (2014, 2015 and across the years). The more staff believe this to be the case, the more satisfied patients will be on average.”

Racism and bullying undermine psychological safety at work. This matters because as Carter and colleagues demonstrated, inclusive and compassionate leadership helps create a psychologically safe workplace where staff are more likely to listen and support each other, resulting in fewer errors, fewer staff injuries, less bullying of staff, reduced absenteeism and (in hospitals) reduced patient mortality.

An inclusive work team recognises, as Edmondson (1999) puts it, the deep human need to belong, and the anxiety anyone may feel when speaking up or sharing ideas in front of others for fear of saying something that may appear stupid or wrong.

Inclusion may be regarded as the extent to which staff believe they are a valued member of the work group, in which they receive fair and equitable treatment, and believe they are encouraged to contribute to the effectiveness of that group. Inclusive workplaces and teams value the difference and uniqueness that staff bring and seek to create a sense of belonging, with equitable access to resources, opportunities and outcomes for all, regardless of demographic differences.

As Shore (2018) put it, Inclusive organisations are more likely to be ‘psychologically safe’ workplaces where staff feel confident in expressing their true selves, raising concerns and admitting mistakes without fear of being unfairly judged.

Or as Professor Scott E Page describes in The Diversity Bonus: How Great Teams Pay Off In The Knowledge Economy (2017) – when more diverse representation is underpinned by inclusion, demographic diversity can improve team performance. The evidence for this is more nuanced than is sometimes presented, but is convincing nevertheless. An evidence base supports the proposition that effective leadership is diverse, inclusive and compassionate.

Psychological safety and inclusion impact positively on organisational effectiveness. When more diverse representation within teams and in leadership are underpinned by inclusion, it is likely that performance will improve, creativity and innovation will be greater, turnover will reduce and risks will be better highlighted.

One senior BME nurse put it to me, “I’ve spent my entire career walking on eggshells knowing that should I make a mistake or raise a concern I will be held to a higher standard than my White colleagues. I have more than once joined teams where I am not fully valued for the difference I bring or the insights I can share. Inevitably this affects patient care and safety”.


Tackling racism is first and foremost a moral issue but it is also a crucial part of improving the care and safety of patients and service users whatever their ethnicity.

Employers have a duty of care and a statutory duty to address many of the drivers of staff discrimination. On the resultant risks to staff health, for example, doing so requires that they not only address the risks to individuals but the root causes of those risks. It was remarkable during Covid 19 how employers disproportionately focused on individual health risk assessments rather than exercising their duties under the Management of Health and Safety at Work Regulations (1999 as amended) which require employers to ensure there is a work environment that is, as far as reasonably practicable, safe and without risks to health.

Covid 19 and Black Lives Matter have finally, I think, led to many NHS leaders (not all) asking HOW they can address this issue as a priority, not WHY. To do so we have to stop leaving it to those adversely affected by discrimination to be the ones challenging it. We have to recognise that while overt racism is not normalised in the NHS, the patterns of bias, stereotypes, assumptions and behaviours that characterise systemic racism are well embedded and that they significantly damage patient care as well as healthcare staff.

Roger Kline is Research Fellow at Middlesex University Business School. An earlier version of this blog formed a presentation to The Healthcare Improvement Studies Institute, University of Cambridge November 2021 conference

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Unintended consequences: batch recruitment and improving diversity in nursing recruitment

Research Fellow Roger Kline reviews a paper on the impact of joint-evaluation methods in NHS recruitment

With changes to the recruitment process, one Trust more than doubled the number of applicants reaching Unconditional Offer stage

In a discussion with a group of NHS staff recently I was asked what their Trust might do to speed up progress on race equality in recruitment and career progression. I shared some of the evidence on removing bias from processes and inserting accountability, and in passing suggested that if the Trust wanted to be adventurous it could remove the future line manager from the final appointment decision in order to reduce affinity bias as there was some evidence this could be effective.

They laughed and said. “Ah, that is just what happened by accident here when the line manager was off sick. The interviews went ahead and we got a much more diverse set of appointments”.

A fascinating short paper by Sheila Cunliffe and Catherine Wilkins suggesting this approach might be more widely effective has just been published. I recommend you read the original paper but with the authors’ permission I summarise it here and suggest why they may have found what they did.

The case study

A high profile NHS Trust identified a number of issues with their existing process for recruiting Band 5 nurses and midwives. 63% of applicants were invited to interview and 12% of those received an unconditional offer. The Trust found:

  1. Some managers were taking too long to shortlist leading to high non-attendance at interview and too long to return appointment paperwork after interview
  2. Managers wanted the ‘perfect’ candidate and were unwilling to take someone who needed development.
  3. Candidates applied for multiple roles and, if invited to interview for several of these, only attended interviews for one.
  4. There was substantial attrition of candidates after unconditional offer which meant the number of applicants finally onboarded was below 10% of applicants.

The Trust wanted to know why only 12.3% of candidates reached Unconditional Offer stage.  A deep dive into 32 past recruitment campaigns was undertaken by the Nursing Workforce team doing an exercise in which candidates who had applied for these roles were shortlisted for both –

  1. Suitability for the particular role advertised, and
  2. Suitability for a Registered Nurse (RN) role somewhere in the Trust.

The data produced from this exercise was then compared with the data from the original recruitment exercise.  The outcome was quite extraordinary. 89.1% of applicants were assessed as suitable for a RN role somewhere in the Trust, but in the original recruitment many were being rejected at shortlisting stage as they were not considered suitable for the specific role applied for.  In addition, others were not considered to be in the top 4-6 candidates for that role and rejected in order to have a ‘manageable’ shortlist. This was then followed by candidates who were unsuccessful for the role on offer being rejected after interview with no attempt to offer them a role elsewhere in the Trust. The cumulative effect was that only 12.3% of candidates reached Unconditional Offer stage. 

This exercise led to substantial changes in recruitment processes in Adult Nursing including:

  1. Reviewing the ‘Killer Questions’ criteria in the recruitment system to ensure only candidates who were professionally qualified and registered (or about to be) could apply
  2. Stopping shortlisting. Instead all applicants were automatically invited to book into a generic Assessment Centre at a date suitable for them (the centres were run on a 3-weekly basis)
  3. The Assessment Centres were established on the principle of ‘wrapping our arms around the candidate’, ie with a focus on a more positive candidate experience and giving information about the Trust as a whole, including discussion of potential future career progression
  4. Applicants attending the Assessment Centre were given a generic interview and Situational Judgement Test. The interviews were conducted by panels who were assessing suitability for a RN role in the Trust as a whole and not for a specific post. All candidates were assessed against a common standard. This future line manager was not always on the panel and even if they were, they were assessing for generic roles rather than simply for ones they would be managing in future
  5. A Values and Behaviours 10-minute online test developed with a Psychometric company which reported against the Trust Values and Behaviours framework was also trialled, but this was stopped as a result of insufficient HR resource being available for analysis and evaluation
  6. Individual clinical teams had ‘stalls’ at the Assessment day, enabling candidates to speak with specialists and find out more about their work and then have the opportunity to state their preference for specific areas they wished to work in and/or discuss the areas they were interested in from a career progression perspective
  7. Successful candidates were then placed according to the Assessment Centre results and their preferences where possible
  8. A more flexible approach was taken with candidates – eg if a candidate wished to work in a particular specialism but wasn’t considered ready, they could be offered a role which would give them that additional experience in a 6-to-12-month period
  9. Many candidates received an offer on the day of the Assessment Centre.

The Trust gained an immediate benefit which addressed the original rationale for the exercise.  The volumes of applicants recruited improved substantially with 30.3% of all applicants now getting through to unconditional offer compared with 12.3% before these changes were made.

However, when the team designing these changes then reviewed the success rate of applicants of different ethnicities for Band 5 and 6 posts (as part of a separate investigation into bias in recruitment) they discovered something quite astonishing.

They found that whilst the differences by ethnicity in the likelihood of applicants who applied being shortlisted were significant but small, at interview stage the outcomes were very different.

Fig 1 shows the difference between the interview success rates overall, and by ethnicity, before and after the process changes were introduced.

Fig 1. Success rates of different recruitment processes by ethnicity

Ethnicity% Success Rate from Application when interviewed for specific Trust job (12 months)% Success Rate from Application when interviewed for an RN role somewhere in Trust (6 months)Ratio of White Offers to BAME Offers
Asian  16.1%43.68%  0.76
Black  12.9%35.15%  0.94
Mixed  16.7%25.58%  1.29
Not stated  18.7%73.53%  0.45
Other  14.5%33.33%  0.99
White  24.5%33.01%  1.00

The changes recorded in interview outcomes are striking, resulting in the proportions of ethnic minority applicants getting unconditional offers being much closer to the proportion of white candidates at each stage. 


Why might the outcomes change with a change of process? There are a number of possible reasons.

One explanation is Bohnet’s insight that joint-evaluation of candidates succeeds in helping employers choose, irrespective of an employee’s gender and the implicit stereotypes the employer may hold. Bohnet found employers tasked to choose an employee for future performance were influenced by the candidate’s gender in separate evaluation. Bohnet’s findings have implications for organizations that want to decrease the likelihood that hiring, promotion, and job assignment decisions will be based on irrelevant criteria triggered by stereotypes. In contrast, in joint-evaluation, gender was found to be irrelevant – employers were significantly more likely to choose the higher rather than the lower performing employee.

They concluded that research in behavioural decision-making suggests that employers may decide differently in joint than in separate evaluation because they switch from a more intuitive evaluation mode based on heuristics in separate evaluation to a more reasoned mode when comparing alternatives in joint-evaluation. In addition, joint-evaluation might also affect choices by providing additional data that employers can use to update their stereotypical beliefs about a group to which an employee belongs. By definition, an employer has more data points available in joint than in separate evaluation. Bohnet found that only about 8 percent of the employers engaging in joint-evaluation, as compared to about 51 percent of the employers engaging in separate evaluation, chose the underperforming employee. It seems quite possible that the same principle might apply to the influence of ethnicity on decision making.

This is one possible explanation for some of the difference the change of process made, though without additional information it is not possible to say how significant this change might have been.

A second possible explanation is suggested by research on whether having more than one candidate who is female or is from an ethnic minority affects their likelihood of being appointed from interview. Johnson and colleagues suggested it makes a very considerable difference. Pooling results from three studies they found that when there was only one woman or minority candidate in a pool of four finalists, their odds of being hired were statistically zero.

However when they created a new status quo among the finalist candidates  adding just one more woman or minority candidate, the decision makers did consider hiring a woman or minority candidate. The difference that increasing the number of female or minority candidates made was remarkably large. Why does being the only woman (or ethnic minority person) in a pool of finalists matter? The researchers suggest this is because it highlights how different they are from the norm “and deviating from the norm can be risky for decision makers, as people tend to ostracize people who are different from the group. For women and minorities, having your differences made salient can also lead to inferences of incompetence.”

Clearly in batch recruitment of the sort in the Trust studied, half[SC1] of those shortlisted prior to the change of process were White applicants, so it is possible this was a factor, although it is unlikely to be the main one since substantial numbers of individual shortlists would have had two or more BME candidates (Harvard Business Review).

The third possible explanation, and probably the most significant one, is that the removal of the line manager from the decision making process for specific roles they would manage in future made a difference. Using an assessment centre in which the future line manager was not always present, and even if a manager with a vacancy was present they were they were not necessarily interviewing ‘their candidates’, is likely to have substantially reduced affinity bias. In No more tick boxes I summarised some of the powerful evidence that affinity bias is an important factor in creating biased recruitment and career progression decision. There is evidence that the absence of the future line manager can help to prevent some of that bias. Google follow that approach  even though “Managers hate the idea that they can’t hire their own people. Interviewers can’t stand being told that they have to follow a certain format for the interview or for their feedback.” (Wired)


It is likely that a combination of a very structured process, without the future line manager’s decision being key, possibly assisted by either or both the impact of joint evaluation and more diverse shortlists, helped make the remarkable difference, Cunliffe and Wilkins found.

Either way, there appear to be important lessons for other NHS employers where batch recruitment is possible since, when implemented properly, it may make a very significant contribution to diversity as well as the overall effectiveness of recruitment.

The authors would be really interested in other examples of batch recruitment and the use of assessment centres for such recruitment at, and so would I.

Roger Kline is Research Fellow, Middlesex University Business School

If you found this interesting, you might want to read Roger’s blog about No more tick boxes, his extended review of “what works” and what doesn’t in creating fair recruitment and career progression

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No more tick boxes…

Despite a blizzard of initiatives, inequalities in NHS promotion remain, writes Roger Kline

Even for those who have perfected the art of looking the other way, the last set of data NHS recruitment and promotion date was a shocker.

It was 1.61 times more likely that a White shortlisted candidate will be appointed rather than a candidate of Black and Minority Ethnic heritage who was good enough to be shortlisted.  Nationally, it is twice as likely that BME staff will not believe that there are equal opportunities for career progression and promotion as White staff. These gaps in experience have not improved since 2016 despite a blizzard of initiatives within individual employers and innumerable presentations about “changing culture”.

There has been some improvement. Boards are more diverse and there are significantly more middle and senior managers of BME heritage. But there is near universal acceptance across NHS leaderships that the pace of change is simply too slow.

I have lost count of the number of times I have had BME staff describe to me how they have watched White colleagues – whom they had welcomed, inducted, supported and helped to train – get promoted over them again and again. I have lost count of the number of time I’ve been told how “stretch opportunities” (such as acting up, secondments, and involvement in significant projects) which are the key to career progression have been filled by a tap on the shoulder followed by promotion. I have read many dozen Action Plans on Race Equality which are generally full of good intentions but were never going to make much difference not least because they could not answer the one simple but crucial question we ask of other interventions.

Crucially, the authors of such Action Plans were generally unable to explain why they had confidence that what they were proposing had a reasonable likelihood of achieving the goals their Plan outlined

The death of George Floyd and the evidence of deep workforce discrimination that Covid 19 has highlighted, seems to have prompted large numbers of NHS Boards (but certainly not all) to agree that they cannot carry on doing the same things and expect different results.

The NHS People Plan for 2020-21 states that

employers, in partnership with staff representatives, should overhaul recruitment and promotion practices……… this should include creating accountability for outcomes, agreeing diversity targets, and addressing bias in systems and processes. It must be supported by training and leadership about why this is a priority for our people and, by extension, patients. Divergence from these new processes should be the exception”

But if that is going to happen we need more than good intentions. Progress will require leaders at every level willing to reflect on their own biases, assumptions, stereotypes and behaviours. It will require leaders to understand what sorts of interventions might work better and why. The search for one-off “silver bullets” such as diverse panels or diversity training must end. We should certainly call out Boards for failing to “move the dial” but we must also be able to demonstrate what might work better and explain why. We need an evidence-based strategy underpinned by both honesty about where we are and a credible theory of change to move us on.

That must include being driven by what research says will mitigate bias in recruitment at every stage – the job description, how it is advertised, appraisals, shortlisting, assessment, interview and ‘onboarding.”

“No More Tick Boxes” is the first attempt to review the evidence on how to make recruitment and career progression fairer. It summarises the research and sets out a framework that aims to establish a methodology to guide those seeking more effective strategies.

It sets out, heavily referenced, key steps organisations must take is they are to redress the current patterns of discrimination and waste of talent.

Firstly, without understanding what needs to improve, failure beckons. That means Boards need a “problem sensing” approach not a “comfort seeking” one with granular attention to data and listening to lived experience.

Secondly, we have to accept that the dominant HR paradigm on recruitment and career progression has failed. It has relied on a trinity of policies, procedures and training whose stated purpose is to set fair standards and make it safe and effective for staff to challenge unfair decisions. But research makes clear this is a flawed model, not just for recruitment and career progression but in other respects too – whether to promote the safe raising of concerns, prevent bullying and harassment or stop unfair disciplinary action. It is not just that it hasn’t worked, it was never going to.

Policies and procedures rely on individuals being brave or foolish enough to raise concerns when the evidence is that this rarely works and may well make things worse. Ask yourself: how many people in your own organisation who challenged an appointment or raised a bullying grievance won and were then thanked for doing so?

As for diversity training, a very large research project into workplace diversity by Kalev and Dobbin found “The most effective [diversity] practices are those that establish organisational responsibility: affirmative action plans, diversity staff and diversity task forces. ……Least effective are programs for taming managerial bias through education and feedback.” It does not mean training should be abandoned –like unconscious bias training it can certainly improve cognitive understanding. But it does mean we should stop assuming that in isolation it could decisively change decision making. It will not.

As innumerable researchers have discovered, when people are watched, have to account for their acts and omissions, and there are consequences for inaction their behaviour changes and so do outcomes. Accountability is key. Accountability can take many forms and evidence strongly suggests it is an essential element of improving fair recruitment and career progression practice. It may take the form of:

  • Accountability nudges;
  • Accountability for individual decisions such as panel decisions or appraisals;
  • Data driven accountability such as through an “explain or comply” approach which scrutinises patterns of decision-making across an organisation or parts of it.

These three approaches, especially in tandem, are far more effective than relying in individuals to challenge specific decisions retrospectively or hoping training will prevent bias. An “explain or comply” approach does not equate to an organisational mugging. It asks department and divisional leaders to explain disproportionate outcomes for staff with protected characteristics. Unless there is a satisfactory explanation (possible but unlikely) they are expected to engage with colleagues (including HR and OD) to change their processes and improve outcomes. This makes this no different to how any other KPI should be approached.

Thirdly, the organisation’s focus should be on removing bias from systems and processes, rather than relying on removing bias in human beings. We need to remove or mitigate the numerous ways in which bias affects decision making at every stage of recruitment, development, promotion and support once employed. That means replacing the frequently sloppy recruitment processes in the NHS and elsewhere with an evidenced approach to creating a post; identifying essential criteria; advertising; shortlisting; appointment methods; scoring and decision making; and onboarding.

For example, that means a small number of key competencies underpinned by the evidence of what makes for effective, inclusive, compassionate staff since they are the ones who in an inclusive environment will be the most effective staff as well as the best leaders. That means shortlisting and interviewing that is well structured, with a clear success profile and a clear scoring matrix alongside other assessment methods such as situational judgement tests which research suggests have both good predictive and equality outcomes. And that requires granular attention to how to mitigate bias.  This should be done alongside effective positive action and appraisals as part of a talent management process.

Fourthly, research is clear: leaders (at every level), who understand and reject discrimination can make a fundamental difference to sustainable outcomes on diversity. They need to model the behaviours they expect of others, understand the importance of diversity and inclusion, listen with attention and hold themselves and others to account on the outcomes of their interventions and strategy. To be able to do this effectively, leaders need to understand their own biases, stereotypes and assumptions, accept challenge and gain insight into how they need to change personally in order to do this.

Fifthly, most Equality Action Plans still emphasise positive action not institutional change – a ‘deficit model’ – focusing on helping the staff who are discriminated against rather than the institutional practices that discriminate. Yet whilst encouragement and support are important for under-represented staff groups, without changing institutional blockages and biases they will have limited impact

Sixth, ensure transparency and positive action in relation to ‘stretch developments’. The NHS has adopted the 70:20:10 model of staff development, which suggests that stretch developments and their consolidation are the most important drivers of career progression. So acting up posts, secondments, and involvement in project teams should never be filled informally, and access should be monitored and, where appropriate, filled preferentially through positive action for under-represented groups to help level the playing field. And where disproportionate access exists an “explain or comply” approach should be mandatory.

Seventh, for diversity to be sustainable and make a difference to staff experience and patient care, inclusion – not just improved representation – is essential. Whether specific interventions (including those rated as more effective) are actually effective depends on the extent to which teams feel psychologically safe, difference is welcomed, and all staff are listened to and valued. Without inclusion, staff from under-represented and disadvantaged groups will be less engaged, become outsiders be held to a higher standard than other staff, and be at risk of higher turnover –with adverse impact on organisational effectiveness and patient care and safety.

Eighth, a “command and control” approach, in which front line managers are simply told what to do, won’t work. It will lead to pushback unless senior leaders are seen to model the behaviours they expect of others, take time to discuss the new strategy and the evidence behind it, and why it will make the services provided to patients and users better. It will backfire unless serious effort is put into improving inclusive behaviours so that new joiners, of whatever background are welcomed into a safe environment where their difference is seen as an asset. Inclusive recruitment needs to be seen as a crucial part of service improvement, not simply a matter of compliance

Finally, this approach, strongly underpinned by research evidence, requires trade unions as well as HR directors to move away from relying on individual casework driven by complaints, towards proactive and preventative work to embed accountability and interventions backed by evidence. It means welcoming the renewed interest in social justice, but demands that we move on from just talking about the need for “culture change” towards understanding and acting on the evidence of what is most likely to work.

The existing approach to recruitment and career progression has sometimes felt like trying to navigate the London Underground with a map of the Paris Metro – we were never going to get where we wanted to. There are signs that this different approach set out in this review is gaining some traction. But the window of opportunity will start to close unless we start to change at pace whilst recognising change is complex and will take time.

No more tick boxes: a review of the evidence on how to make recruitment and career progression fairer was published on Thursday 16 September by NHS East of England

Editors Picks Social commentary

Working backwards with No. 10

Roger Kline is Research Fellow at Middlesex University Business School. In this blog he responds to the employment section of the controversial recent Commission on Race and Ethnic Disparities.

First, the pre-determined conclusion

The Government’s Commission on Race and Ethnic Disparities report is part of a political project mapped out some time ago.

In 2017, Munira Mirza, the (now) head of the No 10 Policy Unit, who commissioned the Sewell Commission) dismissed the concept of institutional racism claiming “a lot of people in politics thinks it’s a good idea to exaggerate the problem of racism”.

In 2019, Liz Truss, the Minister for Women and Equalities, said ”too much ground had been ceded to the Left on issues of identity […] We need to reassert the value of individual and character above the particular type of group you might happen to be a member of […] I think there’s been too much identity politics in Britain”.

Nine months ago, Kemi Badenoch, the Equalities Minister, having claimed (falsely as the subsequent leaks confirmed) that the Fenton Review on COVID-19 did not make recommendations, then “hit back at claims ‘systemic injustice’ is the reason ethnic minorities are more likely to die from coronavirus in England.”

Their collective views individualise the challenge to inequality, undermine collective challenge and institutional interventions. The idea of institutional discrimination is denied, whatever the data may show. There is an emphasis on individual effort rather than collective challenge, underpinned by the assertion (contrary to the evidence) that we live in a meritocracy where all may equally, irrespective of identity, rise to the top.

One crucial obstacle to this view of social policy is the MacPherson Report (1988) which analysed discriminatory practices within the Metropolitan Police in a manner applicable across all public services as:

The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racial stereotyping.

One purpose of the 2021 Commission on Race and Ethnic Disparities Report is to undermine that insight and instead counter pose individual effort to collective change.

In reaching its pre-determined conclusion it plays fast and loose with both data and research.

…Now, the evidence

Take the section on public sector (especially NHS) employment; there is no sense that the conclusions either flow from the assembled evidence or are a coherent whole.


Whilst the Commission attributes evidence of race discrimination to individual cases not to a pattern of structural discrimination, several of the Commission’s proposals (some of which are helpful) appear to acknowledge that there are indeed patterns of discrimination not just the individual instances the report argues are the norm.


The authors appear to have neither interrogated the very large NHS database on workforce and staff survey metrics, nor discussed their proposals with those leading the NHS work on workforce race equality including the Workforce Race Equality Standard.

The NHS database conclusively demonstrates that patterns of race discrimination do exist in NHS recruitment, promotion, development, discipline and bullying, and that they are so systematic and sustained that it is difficult not to conclude that Macpherson’s definition applies to the NHS.

Indeed the Commission itself appears to come close to accepting that institutional race discrimination as defined by MacPherson exists when it accepts that “Human beings tend to discriminate, even when unintended” (p.122) and that “it is possible to have racial disadvantage without racists”.


The authors suggests that the lived experience of racial bias is a matter of “perception”. The Occupational Preferences report (p.120) they commissioned found that respondents felt:

  • Being a manager is a risky choice
  • Feedback to become a manager is poor.

It is hard to know why this section is included at all. The sample is small (n=116), not representative (“an uneven distribution for gender, White and ethnic minority groups, and full and part-time employees”), and the conclusions are hardly new.

The refusal to accept that bias is a real and dynamic factor is repeated (p.123) where, discussing recruitment, the report states, “there is a perception that people at the top tend to have affinity bias, appointing people in their own image.”  

The Commission’s conclusion is that, “there are simple HR activities which can address these perceptions”. There is not even a hint in the report as to what the “simple HR activities” are that can address these “perceptions”.

That may be because these are not “perceptions” but are grounded in the widespread lived experience of BME managers across the NHS. In fact, the bias experienced is not ethereal but grounded in systematic discrimination at work.

There is a body of research showing how Black and Minority Ethnic (BME) managers are held to a higher standard and that feedback to BME staff (including appraisals) is systematically poor. Those systematic and sustained processes are what needs to change but “simple HR activities” that deny those processes exist won’t achieve that.


The report (p.121) unwisely launches an assault on the gold standard social audit research conducted in both the UK and the USA. Their results, replicated on several occasions by different researchers in different contexts, demonstrate that when identical job applications are submitted with one ‘English’ sounding name and one ‘foreign’ sounding name, this results in much greater likelihood of applicants being shortlisted if their name sounds ‘English’.

Such findings strongly suggest systematic racial bias, not the odd example of racism.


The report (p.125) states

“Most researchers remain sceptical about the impact of unconscious bias training, quotas and diversity specialists. Research by Kalev and Dobbin, published in the Harvard Business Review, found that mandatory diversity and inclusion measures have not always been successful.

Quotas have been slipped in to this sentence but it is not clear why, as they are not advocated by the NHS and are unlawful in the UK.

Targets are not unlawful, but are quite different. They are used across many aspects of employment (including by the UK Government) and there is a body of evidence demonstrating that whether they are called targets or goals, they can be effective, depending on how they are used.

The report is rightly sceptical of the impact of unconscious bias training (UBT) on decision making and it is true that too often employers have treated UBT as a silver bullet to tackle discrimination. However, as the report rightly accepts such training can play a role in improving the cognitive understanding of bias:

“[…] the Commission recognises the place of such practices (diversity and unconscious bias training) in the journey to promote diverse and inclusive work environments.”

The Commission rightly then states:

“[…] that diversity and eliminating disparities requires impactful organisational redesign and training that leads to truly inclusive environments.”

And on p.125:

“Organisations can be (re)designed to change behaviour, and therefore outcomes.”

It then muddies the argument by providing a rather random list of such measures which are of varying effectiveness and completely fails to include those measures that research highlights are essential such as debiasing processes and inserting effective accountability.

It states:

“This indicates ‘nudge’-style procedures (such as name-blind CVs, transparent performance metrics, family friendly policies, proactive mentoring and networking procedures) are more useful than methods that overtly discriminate against some groups, for example quotas.”

It raises again the straw argument of quotas. Its statement that, “research by Kalev and Dobbin, published in the Harvard Business Review, found that mandatory diversity and inclusion measures have not always been successful” is, of course, true. There is no magic wand.

However, Kalev and Dobbin are strongly in favour of accountability (both internally and externally) and provide evidence as to why, not just nudges. Indeed the Commission’s recommendation on the CQC role seems to suggest the Commission agrees.


The report notes (p.116) that ethnicity pay gaps are relatively small at NHS senior manager level and very between different BME groups and white staff and concludes:

“Such a picture is not consistent with a pattern one might expect of systemic discrimination, although undoubtedly, there will be cases of discrimination and bias in what is the largest employer in the country.”

This appears to be the only evidence in the entire report produced in support of the claim that there is no “systematic discrimination” in the NHS.

This conclusion ignores the rather obvious question about why the proportion of senior managers from BME backgrounds has been (and still is) so much lower than the proportion of senior managers from White backgrounds. It ignores the detailed data showing that currently across all grades it is 1.61 times more likely that White staff will be appointed once shortlisted compared to BME staff, and that there is a steep ethnicity gradient in which the proportion of BME staff declines as the grade gets higher.

For example, 27.5% of Band 5 Agenda for Change staff are from BME heritage but this drops at senior manager level to 10.5% (Band 8C) and 8.0% (Band 8D), something not mentioned in the report.


The Report counter-poses cognitive bias to demographic bias. It states:

“Greater emphasis should be placed on diversity of thought and perspective around a board table which is not associated with anyone’s race or ethnicity.”

This feels like a polite version of Dominic Cummings’ claim that people “talk a lot about ‘diversity’ but they rarely mean ‘true cognitive diversity.’ They are usually babbling about ‘gender identity diversity’ […] What [we need] is not more drivel about ‘identity’ and ‘diversity’ from Oxbridge humanities graduates but more genuine cognitive diversity”.

In fact we need both cognitive and demographic diversity since, as Scott Page (2017) and others demonstrate, they are not alternatives but very significantly overlap.


The employment section of the Commission report demonstrates the danger of reaching conclusions and then looking for evidence to support them.

It will not assist the work to reduce racism in public sector employment and risks doing the exact opposite unless rebuffed.

Health & wellbeing

A tale of two metrics

Roger Kline, Research Fellow at our Business School, discusses the two main findings from the 2020 NHS Workforce Race Equality Standard report.

The 2020 NHS Workforce Race Equality Standard (WRES) report is out.

There has been a sustained and significant closing of the gap between the treatment of Black and Minority Ethnic (BME) staff and White staff in disciplinary action. The progress on disciplinary treatment, however, is in sharp contrast with the standstill around recruitment and career progression.

Black nurse in green scrubs, face mask and blue gloves holding a clipboard of papers

What are the key findings?

Firstly, a growing number of Trusts have adopted a simple accountability nudge which aims to interrupt bias by requiring line managers to explain to a very senior manager, prior to any disciplinary investigation being started, why a formal disciplinary investigation is the only way of addressing an alleged concern.

Secondly, the parallel moves towards a just and learning culture (rather than blame) in a growing minority of Trusts (pioneered by Mersey Care) have led to a similar accountability nudge emphasising early informal intervention.  

It is a pity that neither of these interventions were prompted by any national initiative but in combination they seem to be working as research suggested, possibly compounded by some form of “Hawthorne” effect.

There may be some managerial attempts to do “workarounds” on the accountability nudge but there is no evidence this is on a large scale. These two approaches together save a large amount of management time, benefit wider culture change, and stop much unnecessary disciplinary action.

Comparing the numbers

In the last four years, the total number of NHS staff in England entering the disciplinary process has dropped from by 28.2% from 15,711, to 11,278 in 2020.

In the same period the relative likelihood of BME staff entering the disciplinary process has substantially closed from 1.56 to 1.16.

What explains this dramatic change when the other key WRES metric on recruitment actually got worse 2016-2020?

Table: Staff entering the disciplinary process 2020

Total White staffWhite staff entering the formal disciplinary processWhite staff likely entering the formal disciplinary processTotal BME staffBME staff entering the formal disciplinary processBME staff likely entering the formal disciplinary processRelatively likely BME staff compared to White staff

A comparison of how tackling these two metrics has been undertaken is telling. Whilst there has been some limited progress in the diversity of very senior posts, the standstill over the last two years amongst middle and lower grades reflects the failure to apply research evidence to the challenge.

By contrast, in 2016, I suggested that the NHS needed to change how we approach incidents that might normally lead to formal disciplinary investigations. The suggestions was to use the almost forgotten NHS Incident Decision Tree and combine the research evidence about the reasons for the disproportionate disciplining of BME staff in the NHS to create a new approach to “incidents”. The Incident Decision Tree was a simple but sophisticated means of asking four questions about an individual involved in a patient safety incident with a view to deciding if suspension was appropriate. 

This is not a new problem

Research commissioned in 2008 by NHS Employers highlighted the disproportionate disciplinary action against BME staff and subsequent evidence showed the discriminatory patterns of discipline involving midwives in London.

In 2017, the very significant variation between NHS Trusts as to the likelihood of White and BME staff being disciplined or suspended was noted and an accountability nudge was again advocated to interrupt bias and focus on learning not blame.

The NPSA Incident tree guidance argued:

“We know from research carried out in the NHS and in other industries that system 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.”

I know of no evidence that greater levels of disciplinary investigation and action in healthcare lead to improved care. No one knows how much NHS time and energy is wasted on unnecessary disciplinary investigations, suspensions, hearings, and appeals, but it is a lot.

What’s the cost?

In 2018, Duncan Lewis and I estimated a typical bullying case cost employers around £40,000 (management time, sickness leave costs, cover, early retirement, replacement costs) excluding legal costs and the cost of professional regulator referrals and it is likely that is the figure for disciplinary cases is similar.

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. An environment of blame, allied to a steep authority gradient 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 had become the default position without there being proper consideration as to whether that is necessary.

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.”    

More recently we explored some of these issues again. 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. Bias is pervasive in workplace investigations, and this is especially true when the alleged “suspect” is of BME origin.

The data is good news for staff and patients

This different approach will not prevent the need, sometimes, for disciplinary investigations and sanctions. But the benefits are clear.

It is time to pay similar attention to identifying and implementing evidence based interventions to end race discrimination in NHS recruitment and career progression. That is surely the next big challenge for the NHS.

Less rhetoric, more practical action rooted in mitigating bias through accountability. That’s what research strongly suggests will work and it is good news that the revamped WRES team are focussed on that.

Coronavirus and COVID-19 Health & wellbeing

COVID-19 deaths and NHS staff. What can we conclude?

Roger Kline, Research Fellow at Middlesex University, highlights the three principles NHS organisations should take forward immediately to avoid unecessary staff deaths.

Well over a hundred NHS staff have died from COVID-19 and we’re not clear why.

COVID-19 disproportionately impacts on some groups of people but we have known for a long time that it was likely to. The NHS nationally failed to ensure (or even ask whether) all employers conducted the statutory risk assessments which should have been carried out weeks ago and which might have prevented some of the tragic staff deaths and illness we have seen.

There are growing signs that the NHS nationally and individual employers are starting to do what should have been done weeks ago.  I want to suggest three principles which should inform employers’ approach going forward

1. What employers do can make a substantial difference

When the deaths of 119 NHS staff were analysed by three leading clinicians they  found that the proportion of nursing and support staff who died from COVID-19 was three times as high as their proportion in the NHS workforce and for doctors it was twice as high.

But their most remarkable finding seemed to largely slip under the radar.

Anaesthetists, intensive care doctors and by association nurses and physiotherapists who work in similar settings are believed to be among the highest risk groups of all healthcare workers because they care for the sickest patients with COVID-19, undertake airway management and have high risk of viral exposure and transmission.

However the analysis found there were no anaesthetists or other intensive care doctors amongst those who died. They found that of those whose speciality was identified, none were described as intensive care nurses. There were also no deaths of physiotherapists reported. The researchers conclude that

…the reason for this is not known and data on infections and serious illnesses are important to consider as well as fatalities, but this data is also currently lacking. What is likely is that these groups of healthcare staff are rigorous about use of personal protective equipment and the associated practices known to reduce risk (emphasis added).

It may be that this rigour is protecting staff better than some fear and the results can be considered cautiously reassuring. However, this finding is not a reason to slacken off on the appropriately rigorous use of PPE, but rather to wonder why others, who are likely involved in what are generally considered to be lower risk activities, are becoming infected and consider whether wider use of rigorous PPE is indicated.

What implications does this have for NHS employers? The researchers suggest a crucial one

It is not possible to know whether infection occurred at home or at work, but we have determined that the vast majority of individuals who died had both patient-facing jobs and were actively working during the pandemic. It seems likely that, unfortunately, many of the episodes of infection will have occurred during the course of work.

Had the statutory risk assessments been undertaken several weeks ago as they should have been, they would have highlighted  the greater risks to some groups of staff and inevitably recommended special attention be paid to eliminating or mitigating those risks.

The risks were:

  • Staff from any backgrounds with long term health conditions would be especially vulnerable to a Coronavirus pandemic
  • BME staff being amongst those groups especially prone to such long term health conditions
  • BME staff being disproportionately represented amongst lower graded front line health and social care staff who might generally be at greater risk  
  • BME staff have been found to be less likely to raise safety concerns either because they do not believe they are listened to or because they fear the consequences of doing so
  • BME being more likely (I’ve not seen robust data on this) to work night shifts where communication and safety measures may be more poorly managed

In addition, there has been significant anecdotal evidence that BME staff believe they are being disproportionately placed on wards with greater COVID-19 risks where staff are reorganised on a temporary basis to cope with the pandemic.

Finally, those dying do not look like those making the decisions. There is a steep ethnicity gradient across the NHS with career progression much harder for BME staff and senior positions generally well out of reach despite some recent limited progress. Diverse teams make better decisions and we don’t have nearly enough diverse senior leadership teams prepared to put themselves in other peoples’ shoes.

At a time when PPE was in serious shortage, these factors contributed to a perfect storm. The results are in the news bulletins every day. The risks were reasonably foreseeable. However, not only were many of these deaths probably avoidable but if the right measures are taken now by NHS employers, the death rate and illness rates amongst all staff but especially BME staff can be radically cut. 

For that to happen two other conditions must be met.

2. Employers must take prime responsibility for staff health, safety and well-being

The statutory requirements on health and safety at work of employees, and the statutory requirements in respect of equality are primarily for employers to actively implement rather than for employees to complain when they are breached.

For example:

  • Section 1 (2) Health and Safety at Work etc Act 1974 states: “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees.”
  • Regulation 3 (1) of the Management of Health and Safety at Work Regulations 1999 provides that: “Every employer shall make a suitable and sufficient assessment of the risks to the health and safety of his employees to which they are exposed whilst they are at work; and the risks to the health and safety of persons not in his employment arising out of or in connection with the conduct by him of his undertaking”
  • The Personal Protective Equipment at Work Regulations 1992. Regulation 4 (1) provides that “every employer shall ensure that suitable personal protective equipment is provided to his employees who may be exposed to a risk to their health and safety except where and to the extent such a risk has been adequately controlled by other means which are equally or more effective.”

At the same time however, human resources practice has steadily drifted towards a culture where policies, procedures and training are put in place which focus on enabling individuals to safely raise concerns rather than the employer being proactive and preventative. The problem is that such an approach does not work. Research on bullying, for example, concluded that

In sum, while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace, there are significant obstacles to resolution at every stage of the process that such policies typically provide. It is perhaps not surprising, then, that research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces.

Similarly for equality:

…attempts to reduce managerial bias through diversity training and diversity evaluations were the least effective methods of increasing the proportion of women in management […] programmes which targeted managerial stereotyping through education and feedback (i.e. diversity training and diversity evaluations) were not followed by increases in diversity.

There has been a similar approach in respect of staff raising concerns (whistle blowing) where it is still left far too much to individual members of staff to be brave or foolish enough to raise concerns rather than employers proactively intervening to change the organisational climate at work.

The wider industrial relations context over the last three decades has been one that has seen a move away from ‘collective bargaining’, towards one that has relied much more on a floor of employment rights that is overwhelmingly individualist in nature. Even when individuals successfully challenge inappropriate decision making using employer policies and procedures, they often have little impact on the conditions of other workers other than possibly tightening up employer policies, procedures and training, which are designed as much to defend employers as to improve outcomes – impacting on what trade unions can achieve

In respect of COVID-19, therefore, it is crucial that the emphasis is on clear expectations, monitored by both the CQC and NHSi/E, that employers will act decisively to protect all staff and especially those that evidence suggests are most at risk.

This should be done through:

  • Urgent risk assessments made public and involving staff and unions
  • The provision of suitable and safe PPE
  • Enhanced staff testing
  • Enhanced data collection and analysis to assist proactive intervention
  • Enforcing social distancing and ensuring that staff who can do so work from home subject to service needs
  • Actively listening to staff and acting on their concerns and suggestions, and ensuring it is safe to do so

3. The narrative is crucial

All employers have a statutory duty to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all their employees. It is one aspect of the duty of care owed by all employers to their employees, contractors and visitors.

No member of staff should be exposed to risks that are reasonably foreseeable and which can be eliminated or mitigated. We know that some groups of NHS staff are at particular risk, notably those with underlying health conditions. We know that Black and Minority Ethnic staff are amongst those particularly at risk and are disproportionately working on the front line in lower graded roles, subject to more bullying, more reluctant to raise concerns, and may be more likely to work night shifts.

It is therefore especially important that when undertaking and acting on risk assessments Black and Minority Ethnic staff are accorded particular attention because they may be at greater risk, as the death and infection rates from COVID-19 for NHS staff as a whole show.

Failure to do so would be a breach of the employer’s duty of care and would risk unnecessary harm. Let us be clear. This is not an alternative to addressing the risks faced by all staff and ensuring all staff are as safe as possible, but is an integral part of such an approach which recognises that some groups, notably BME staff, are especially at risk.

The initial analysis of NHS staff deaths suggest that where the statutory requirements are fully met, risk is indeed greatly reduced. There is no time to be lost in taking the steps suggested especially as individual trusts and the NHS nationally have now accepted there is much to be done, and at speed.

Health & wellbeing

The depressing state of bullying in the NHS

Roger Kline, Research Fellow in our Business School discusses the shocking level of bullying in the NHS.

The numbers are out

The latest NHS national staff survey is out. It shows, yet again, that an extraordinary proportion of NHS staff report being bullied or harassed at work by managers and colleagues last year (2019).

The figures show that 13.1% of staff reported that they were bullied, harassed or abused at work by managers (slightly down from 2018) and 20.6% reported being bullied, harassed or abused by colleagues (slightly up from 2018). Equally depressing is that less than half (48.6%) of those who experienced or witnessed bullying and harassment said they actually reported it (although this is up from 47.0% in 2018). 40.3% of staff reported feeling unwell as a result of work-related stress, which is up from 39.8% in 2018 and 36.8% in 2016. Some 22.9% also said they had unrealistic time pressures, up from 20% in 2018.

In previous years, BME (Black, Minority and Ethnic) staff were more likely to be bullied by colleagues than white staff. Staff with disabilities were more likely to be bullied, harassed and abused than staff without a disability. LGBTQ staff were more likely to be bullied, harassed or abused than other staff. It is the same this year and the ambulance sector remains the worst sector for bullying.

It is a tribute to the extraordinary efforts of NHS staff and managers that despite these pressures, more staff reported being happy with the quality of care they can provide. A higher number also said they would recommend their place of work for treatment.

The levels of bullying are higher in public services than any other sector and higher in the NHS than in most public services. Whilst there are individual employers whose data has improved the overall picture is bleak. There is no sustained progress at all across the NHS in England despite initiatives, speeches and circulars.

A woman in blue scrubs sits on the floor with her head in her hands

The impact of bullying

The 2013 Francis Inquiry found there was a “pervasive culture of fear” in the NHS and certain elements of the Department for Health which has been enabled by top-down management, “control totals”, “savings targets” staff shortages, constant reorganisation and a culture of blame. Research shows there are several “incubators” for bullying, some of which are easier to tackle than others in a health service severely squeezed by a decade of austerity.

Like all employers, the NHS has a significant sprinkling of corporate psychopaths who enjoy bullying and use it to drive their career ascendancy. However, where research has established links between bullying and those with such personality traits, it is context that seems crucial. A wider toxic workplace environment gives permission for such behaviours, colludes in it and leaders may even role-model bullying. A different context can prevent such behaviours or move such individuals on.

NHS leaders are aware of the impact of bullying. We know it adversely impacts on staff mental and physical health and wellbeing. It’s closely linked with increased intentions to leave, job satisfaction, organisational commitment, absenteeism, productivity and the effectiveness of teams, all of which cost the NHS at least £2.28 billion annually.  

Managing NHS staff with respect and compassion correlates with improved patient satisfaction, infection and mortality rates (Care Quality Commission (CQC) ratings and financial performance). Bullying undermines team working and is the antithesis of the inclusive working in which psychological safety and compassionate leadership can drive innovation, creativity, staff engagement and productivity. 

Why has the NHS failed to tackle bullying?

Every NHS employer has a “dignity at work” policy and related procedures and training. Crucially, the NHS response to the epidemic of bullying and harassment has been divorced, until very recently, from the research on workplace bullying and harassment. The dominant Human Resources (HR) paradigm has seen policies, procedures and training as the prime means whereby individual staff can raise concerns about bullying and harassment which HR then investigate and support if legitimate. However, research suggests this approach is fundamentally flawed as a means of improving organisational culture in isolation.

HR has tended to regard bullying behaviours as the exception, whereas data and research suggests they are widespread. Employers have a wealth of local data (staff survey, turnover, sickness rates, exit interviews) on the prevalence of bullying and harassment which could have enabled them to be proactive and preventative. Yet, despite the data showing vast numbers of staff experience bullying, harassment and abuse, many NHS employers record very few complaints about bullying and harassment.

The research is clear

The current reliance on individuals using policies and procedures to raise concerns has failed because such individualised processes are not built to resolve allegations of bullying and prevent bullying behaviours. Employees have no confidence in such processes because they do not trust the process to be fair. They believe that raising concerns about bullying will make a bad situation worse, raising concerns is ineffective, and too many leaders are failing to model the behaviours they purport to uphold.

Not surprising the ACAS review of the literature and their own experience concludes:

“…in sum, while policies and training are doubtless essential components of effective strategies for addressing bullying in the workplace, there are significant obstacles to resolution at every stage of the process that such policies typically provide […] It is perhaps not surprising, then, that research has generated no evidence that, in isolation, this approach can work to reduce the overall incidence of bullying in Britain’s workplaces”.

What more can be done?

In their review of bullying in the NHS, Illing et al (2013) point out that since the success of a conflict management strategy is highly dependent on other contextual factors in workplaces, a consideration of context is vital if an effective strategy is to be achieved.

Bullying behaviours are best prevented by organisation-wide strategies that focus proactively on ensuring worker wellbeing and fostering good workplace relations. They suggest that the most successful way to address unwanted behaviours in the workplace is to ensure that a culture of trust is built in the organisation. Create an environment where staff (both targets and witnesses) can be open and confident about reporting problems and where individual and collective concerns about bullying are identified and addressed as early and quickly as possible, through supportive and fair processes.

The good news is that there are now, finally, some determined NHS efforts to draw on the research and make changing organisational climate the priority. The work of Civility Saves Lives, initiatives such as the just culture approach pioneered by Mersey Care, the increasing awareness of the importance of preventative and proactive strategies, finally has support amongst some national NHS leaders.

This support is crucial, since it has been the behaviours of Ministers and national organisations, until recently, that have allowed and encouraged the bullying epidemic by counter posing financial targets to patient safety and staff wellbeing goals. One test as to whether NHS national leaders are serious about this improved approach is whether senior leaders whose behaviours are unacceptable are sanctioned or ignored. We’ll see.

Time will tell if the emerging approach is given a chance to demonstrate what the evidence confirms; treating staff with respect is not an optional extra, it is the precondition of an effective and safe NHS.

Business & economics Social commentary

Unconscious bias: now you see it, now you don’t?

Roger Kline is Research Fellow at Middlesex University Business School. Roger would like to acknowledge the helpful assistance in drafting this blog from Peter Daly, Principal Employment Lawyer at Slater Gordon lawyers.

“I am a black woman who has been harassed at work by a white man. My behaviour and the standard of my work has been praised by every witness, by my line manager and in every appraisal. It is accepted that staff surveys and workforce data on bullying, discipline and recruitment in this organisation strongly suggest there is race discrimination here. You have heard what other BME staff have said about their treatment and mine.

“I would therefore like to ask the panel to consider again how they can possibly conclude race played no part in my treatment. It is agreed I was harassed. Whilst there have been no explicit racist comments you should surely consider whether I have been subjected to race discrimination even if the person harassing me denies it or is even unaware he is a racist?”

 This member of staff then pointed out (this is quoted verbatim from a written appeal) that her employer had recently put all its managers through an “unconscious bias” training programme (at significant expense) but now appeared to deny that such unconscious bias might be a factor in her treatment. Whilst the effectiveness of unconscious bias training is in dispute no one disputes its powerful existence.

 The member of staff who shared this with me was a white colleague. He wanted to know how, in such circumstances, the employer could decide racism was not a factor in her treatment when in his view it clearly was.

 This is not a unique case. A fairly recent high profile example came in the recent Employment Tribunal which awarded Richard Hastings £1million due to his treatment by an NHS Trust. In that Tribunal the Court unanimously agreed that “unconscious” race discrimination played a role, a case I wrote about at the time. Just a few days ago the Court of Appeal used a similar approach.

The statutory framework

The law is reasonably clear and is certainly well known (or should be) to NHS Employment lawyers and senior HR staff as follows:

S.26 Equality 2010 (1) (a) and (b) consider what to do if person (A) harasses another person (B) in a manner which constitutes “unwanted conduct related to a relevant protected characteristic, which has the purpose or effect of violating an individual’s dignity or creating an intimidating, hostile, degrading, humiliating or offensive environment for that individual” (my emphasis).

Section 26 (4) then states thatIn deciding whether conduct has the effect referred to in subsection (1)(b), each of the following must be taken into account:

  • (a) The perception of person B above
  • (b) The other circumstances of the case
  • (c) Whether it is reasonable for the conduct to have had that effect.

In the case considered at the start of this blog, it was agreed by the panel that bullying and harassment had indeed taken place. They correctly noted that:

  • There was no explicit racial comment verbally or in writing
  • There was no other direct evidence that the individual manager was motivated by racism in this case
  • Though it was agreed there was an act of harassment (several in fact) which were committed by a white manager to a BME member of staff, but that in itself (rightly) is not proof that the harassment was racially discriminatory. 

However, what they did not then go on to consider, which a reasonable investigation always ought to do, is whether the explanation given for the harassment fully explained what happened.

In doing so they should have considered :

  • the evidence of the accused person
  • the evidence of other witnesses
  • evidence from within from the wider work environment which might be helpful. That would include workforce data and staff survey data which might (or might not) demonstrate a pattern of institutional discrimination.

A summary of what an investigation into such matters might include is found in my previous article about conducting an inquiry into workplace racism. If the explanation provided for the action does not provide a credible explanation for the actions complained of, then the investigator (or panel) should then consider what other cause there might be, including whether the harassment causing the detriment might be considered racially discriminatory.

Case law

In considering whether the act of harassment might be racially discriminatory the courts have made clear that direct discrimination and discriminatory harassment are unlawful, whether or not the motive or intention which led to the act in question was consciously discriminatory.

Thus, whilst demonstrating that direct discrimination or discriminatory harassment has taken place may well involve an analysis of the reasons for the discriminatory treatment complained of, the courts have made it very clear that it is not necessary to show that the person(s) alleged to have discriminated did so consciously since “unconscious” discrimination is also prohibited, as two House of Lords cases made clear.

Lord Browne-Wilkinson noted that claims under discrimination legislation present special problems of proof as those who discriminate;

‘. . . do not in general advertise their prejudices: indeed they may not even be aware of them’. (Glasgow City Council v Zatar 1998 ICR 120, HL)

In another significant case, the House of Lords similarly stated;

Many people are unable, or unwilling, to admit even to themselves that actions of theirs may be racially motivated” (Nagarajan v London Regional Transport and others [1999] IRLR 572 (HL)).

These decisions of the highest court in the land are reflected in lower court decisions. Thus one EAT ruled that a Tribunal will not assume that a person’s actions are free of subconscious bias even if the person is an honest and reliable witness, and one who genuinely believed they were acting for non-discriminatory reasons. (Gellser and another v Yeshurun Hebrew Congregation UKEAT/2016/0190.)

A similar understanding of “unconscious bias” played a crucial part in the Employment Tribunal decision (not appealed) referred to earlier (Mr R Hastings v Kings College Hospital NHS Foundation Trust: 2300394/2016.

Employers must also bear in mind that discrimination (including race discrimination) need not be the main reason for an act or omission to have been discriminatory. Case law has determined it simply needs to have a “significant influence”:

“… the discriminatory reason for the conduct need not be the sole or even the principal reason of the discrimination; it is enough that it is a contributing cause in the sense of a ‘significant influence’.  (Law Society v Bahl [2003] IRLR 640, at 83).

If it is established that there is an instance of negative conduct which could be assigned to race discrimination, and the employer cannot provide a reasonable and adequate explanation that this was not due to discrimination, then the court or tribunal in accordance with s.136 Equality Act 2010 can draw an inference that the negative conduct was caused by discrimination (see also Fox v Rangecroft [2006] EWCA Civ 1112; and Barton V Investec Henderson Crosthwaite Securities Limit [2003] I.C.R. 1205).

The burden of proof

The burden of proof may therefore shift in discrimination cases. Article 8 of the EU Race Equality Directive (No 2000/43) confirms that where a prima facie case of discrimination exists, it is for the respondent to prove that there has been no discrimination. The same approach is legislated at s.136 Equality Act 2010:

(2) If there are facts from which the court could decide, in the absence of any other explanation, that a person (A) contravened the provision concerned, the court must hold that the contravention occurred.

(3) But subsection (2) does not apply if A shows that A did not contravene the provision.”

So, there are two stages than any HR professional (or indeed trade union official) should consider:

  • First, has the person making the complaint of discrimination sufficiently established the facts from which it may be presumed on the balance of probabilities that there has been discrimination?
  • Second – if established – the burden of proof shifts to the respondent based on the balance of probabilities (Meister v Speech Design Carrier Systems GmbH [2012] Case C-415/10 CJEU).

In reaching such a decision the employer should consider whether there may have been any other non-discriminatory reason that satisfactorily and fully explained the detriment complained of. But if they are unable to do so they must bear in mind that:

  • The decision making need not be consciously racist
  • Race discrimination need not be the sole or even the main factor.

In the case summarised at the beginning, the panel agreed there had been harassment and no convincing explanation had been provided for it. The panel (and indeed HR) should therefore have considered, whether in light of (a) the local NHS staff survey and workforce data, (b) the evidence from other BME staff about their own poor treatment, and (c) the fact that the person who suffered negative treatment from a white manager was from a BME background, whether there was a prima facie case that one motivating factor in the treatment of this member was her race.

They did not do so and thus placed the Trust at risk of financial and reputation cost at a Tribunal. More importantly, perhaps, they betrayed the member of staff who plucked up courage to raise the original concern of harassment and in doing so the Trust may have deterred other staff from raising similar concerns.

Many employers now put their managers through unconscious bias training. It is difficult to understand how they can do this and not consider whether such unconscious bias might be a factor in treatment their staff receive.