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  • RogerKline

A serious review of bullying, harassment, incivility and microaggressions

The NHS is awash with policies, procedures and training and declarations of “zero tolerance” of bullying, harassment or incivility but, overall, their impact seems minimal.

New research rakes a refreshing look at what we might do better.

I’ve argued elsewhere that there is little evidential basis to the excessive reliance on policies, procedures and training on a range of employment issues in the NHS.

In other fields of NHS activity, Boards are likely to ask “what confidence can we have that what is proposed has a reasonable likelihood of achieving its aims?”

Until very recently that simply hasn’t happened on interventions purporting to improve the fairness or effectiveness of recruitment and career progression; to make the raising of concerns safe and effective; to reduce levels of bullying and harassment; nor to ensure potential disciplinary issues were dealt with fairly and with an emphasis on learning not blame.

New research and makes a serious attempt to understand why “unprofessional behaviours between healthcare staff” in acute settings exist, and seeks to analyse what interventions work, and for whom. This is an important paper with implications beyond unprofessional behaviours (UB). It  is complemented by a helpful summary and a practical guide:

The authors define “unprofessional behaviours” between staff as including incivility, microaggressions, harassment, and bullying. They note that it is “pervasive in acute healthcare settings and disproportionately impacts minoritised staff……(with) detrimental effects on staff well being, patient safety and organisational resources.”

The NHS is awash with examples of such behaviours. One recent survey found almost one in three female surgeons have been sexually assaulted by a colleague. Annual NHS staff surveys report one in four staff say they were bullied, harassed or abused by colleagues or managers in the last twelve months with Black and Minority, Ethnic staff, LGBT+ staff, and staff with long-term health conditions or illnesses even more affected.

Patient care is undermined by unprofessional behaviours which can impact communication and concentration, reduce trust in teams, and reduce psychological safety which may make staff less willing to admit mistakes or raise concerns.

Unprofessional behaviours also adversely affect staff physical and mental health both for those targeted and for witnesses in turn impacting turnover and engagement. The impact on staff alone has a substantial financial cost of at least £2.3 billion per annum.

The authors “realist review methodology” seeks to understand why an intervention may work in one context but not another. They found interventions to address unprofessional behaviours are still at an early stage of development, and their effectiveness unclear. Of the forty-two studies reporting interventions they examined, not one (none) study assessed improvements to patient safety or included an economic assessment and just seven studies assessed staff well-being or similar proxies such as turnover intention or burnout. They found that interventions and the behaviour change strategies they use were often poorly described with insufficient explanation of how and why they are intended to work.

Key Dynamics

They identified twelve “key dynamics” which should be of interest to every NHS organisation planning an intervention. They include:

  • Interventions need to address systemic factors that contribute to UB not only individual factors. Organisations were found to largely assume that individual, rather than systemic factors, were driving unprofessional behaviours. A focus on individual factors leaves systemic contributors unaddressed and can lead to implementation of interventions which do not tackle the root causes of UB. Interventions focusing on individuals, such as boosting individual resilience, awareness, or ability to speak up can have their effectiveness undermined when systemic contributors, such as tackling workplace culture or design, remain unaddressed, and continue to contribute to UB occurring.

  • Focusing on individual staff can have unintended consequences for psychological safety. When systems are implemented that seek to weed out ‘bad apples’, psychological safety is not improved, patient safety is unlikely to be positively impacted, and systemic issues remain unaddressed.

  • How and why an intervention is expected to work must be clear otherwise evaluations of interventions can be misleading. Existing studies have claimed success or failure based on intermediate outcomes such as ‘level of awareness’ of unprofessional behaviours, or adjacent outcomes such as ‘assertiveness’.

  • Maintaining a focus on why it is important to reduce unprofessional behaviours (e.g., to improve patient safety or staff well-being) is key when designing an intervention to reduce them. Improving the ability to speak up “in the moment” can be essential to improving patient safety. Implementing a reporting system which enables speaking up online at a later time may have no impact on patient safety, unless other strategies are implemented which improve psychological safety when it matters.

  • Encouraging bystanders to intervene is important for culture change but can lead to moral injury. Encouraging bystanders to intervene sends signals that unprofessional behaviour is unacceptable. However, creating an imperative to intervene can also lead to moral injury if staff do not subsequently intervene and feel guilty for not having done so. Further, intervening can place staff at risk of reprisal if performed in an unsafe organisational climate. Staff should be encouraged to intervene only when they feel safe and confident to do so.

  • Interventions must be perceived as authentic to foster trust in management. To assess whether it is worth trusting management to provide a safe working environment, healthcare staff will assess the authenticity of efforts that management make to reduce UB. If an intervention is not seen as authentic, staff may not take it seriously and will disengage. Authenticity can be lost if managers are simultaneously engaging in negative behaviours and sending mixed signals, or if the intervention itself is clearly inadequate for its intended purpose.

  • One size does not fit all—tackling UB generally requires multiple and sustained interventions to address underlying contributors. Many interventions do not address systemic contributors. Rather, they only seek to target one or two contributors (of many) for a limited length of time. However, the existence of this limited intervention may inhibit more comprehensive interventions from being developed and put in place because something is ‘already being done’ (although only partially) about the problem. To be seen as genuine and to have adequate reach, interventions need to include managers and senior employees at all levels. This is especially important for those organisations where managers have been seen to engage or tolerate UB themselves and where trust in management is low.

  • Interventions that are both inclusive and equitable are critical to ensure effectiveness and sustainability and for addressing inequalities. Minoritised groups, women and staff with disabilities experience more unprofessional behaviours in the workplace. Yet these groups are rarely considered in existing interventions. The authors only identified one published intervention seeking to address racism, and none that even mentioned women or minoritised groups. Interventions could, and should, be more targeted and designed to specifically reduce UB for these groups.

While equity is essential to the success of interventions, it can be very difficult to design an intervention that simultaneously addresses the additional burden of UB experienced by minoritised groups and women, while also not singling out or denying opportunities to other staff groups.


Unprofessional behaviours are a pervasive issue which negatively impact patient safety and erodes staff well being whilst undermining organisational effectiveness.  They are yet to be sufficiently addressed by existing interventions, despite the urgent need to do so.

This feels like an important contribution from Jill Maben and colleagues to our understanding and doing better. I’d recommend it.

PS. My wider critique of HR practices (and an alternative approach) in the NHS can be found at

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