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  • Roger Kline

The depressing state of bullying in the NHS

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.

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.

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