The pressure to drive performance can too easily turn a well intentioned manager into a bully, warns Jenny Rogers. NHS organisations must get rid of the blame culture

How to eliminate bullying from the NHS

How to eliminate bullying from the NHS

How to eliminate bullying from the NHS

The word bully is increasingly used loosely and the accusation of bullying is sometimes made as a last ditch defence by a poor performer who is challenged. True bullying means the abuse of a less powerful person by a more powerful one.  

Investigations into bullying in the NHS nearly always concentrate on individuals and their degree of culpability; contrast this with investigations into air crashes

Bullying arises directly out of organisation culture and often starts at the top. When invited to behave in a way that will harm others, two classic 20th century experiments show how readily we will abandon personal moral values and do what we are told. 

Many of Stanley Milgram’s naive subjects applied what they believed (wrongly) were powerful electric shocks to others, and Philip Zimbardo’s nicely brought up students swiftly became abusive “guards” in his Stanford prison experiments. In both cases this was because “someone in authority” said it was OK.

Most bullies believe themselves decent people who are only doing their duty. They are responding to bosses unable to manage the anxiety created by demands from their bosses. Is bullying more prevalent in the NHS than elsewhere? Comparable statistics are hard to find, but it seems unlikely.

However, the status of the NHS as National Treasure does make for unique difficulties. Ministers, desperate to show that they can be trusted with the NHS, fear press attacks; strategic health authorities fear ministerial censure; trust chief executives fear SHA rebukes. The more senior you are, the more you may believe you need statistical proof, hence the importance of targets - and the pressure that may follow.

Many managers do not understand why pressurising does not work. The taken for granted principles of organisation life are based on flawed assumptions so familiar we have stopped noticing them. But 80 years of research has shown not only that they have never worked but that they never could. Senior people do not exclusively know best.

Fear leads to compliance but not commitment. Financial incentives do not increase work satisfaction. Performance appraisals do not improve performance - in about a third of cases it worsens. Threats of punishment merely mean we get better at evasion. Goals set by others are not motivating.

The “firm leadership” recommended in last year’s Department of Health report on alleged bullying at NHS East Midlands and United Lincolnshire Hospitals Trust could just lead to skilled dodging: economy with the truth, illness, presenteeism. Yet the idea that cascading command-control is the way to get results survives in most organisations, despite nods to “empowerment” and “involvement”. When people miss targets the belief is not that the principles are wrong but that they need to be applied with yet more “firmness” - which can degenerate into bullying.

Investigations into bullying in the NHS nearly always concentrate on individuals and their degree of culpability. Contrast this with investigations into air crashes, where no one assumes that any one individual should be blamed. A systemic approach virtually always shows organisational culture somewhere at the heart of what has gone wrong.

How to ensure you are not a bully

  • Moral authority is the only real power: do you have it?
  • Give up over-reliance on telling; make more use of coaching
  • Grow trust through acknowledging feelings; own up to mistakes
  • Have the grounded self-confidence to listen carefully to dissenters
  • Accept your contribution to any relationship problem: you are 50 per cent of it
  • Take a systems approach to problem solving
  • Solicit feedback; offer it skillfully to others
  • Learn to manage your own stress and anger
  • Be tough: challenge bullying immediately. Not to do so implicitly endorses it

What kind of culture is predisposed to bullying?

  • Rigid, complex hierarchy; belief that job titles bestow power
  • Excessive pressure to achieve targets with little attention to human cost
  • Emphasis on money and status as rewards
  • Preoccupation with control; when this fails, redoubling it
  • Endemic fear of blame; hiding mistakes and uncertainties
  • Decision making concentrated at the top
  • Feedback confused with criticism
  • Impatience with “touchy-feely stuff”
  • Dissent seen as “troublemaking”
  • Lack of systemic view: last person in the chain gets the blame