With nearly a quarter of the workforce reporting being bullied, isn’t it time we introduced a national strategy on the issue asks Roger Kline

“The NHS has to make more effort to tackle bullying among staff,” says health minister David Prior. He is absolutely right. I have long failed to understand why the NHS does not take this issue more seriously.

There is a wealth of evidence that bullying makes NHS staff ill, severely affects self-confidence and self-worth, and leads to diminished performance. We know bullying carries an immense financial cost to healthcare organisations.

‘The cost of bullying and harrassment was nearly £9m a year for every one per cent of an organisation’s workforce that experienced it’

Ten years ago, when reported NHS bullying levels were much lower, the Department of Health commissioned research that calculated the cost of bullying and harassment, taking account of sickness absence, replacement costs, productivity losses, litigation and service delivery. The cost was nearly £9m a year for every one per cent of an organisation’s workforce that experienced bullying and harassment.

US research was equally alarming. Staff felt that there was a strong correlation between disruptive behaviours and adverse events (67 per cent).

Record levels

Although levels of bullying of NHS staff by managers and colleagues are at record levels, and there is growing literature about the impact on staff, there is no national strategy to prevent bullying damaging patient care.

With honourable exceptions, too many trusts don’t tackle this issue until it is highlighted in a report by the Care Quality Commission. We know from the annual NHS staff surveys that bullying has increased significantly in recent years and that, last year, 22 per cent of NHS staff reported they had “experienced harassment, bullying or abuse from staff (including managers) in the past 12 months”.

The same surveys show that reporting of bullying has fallen from 54 per cent to 42 per cent over the last decade and is still falling.

In his 2013 public inquiry into Mid Staffordshire Foundation Trust, Sir Robert Francis rejected the conclusions of research commissioned by Lord Darzi that there was a “pervasive culture of fear in the NHS and certain elements of the Department for Health” and that “the NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.”

‘The willingness of doctors to raise concerns declines from the start of training’

Sir Robert was persuaded then that this claim was an exaggeration. By 2015 however, he devoted an entire section of his Freedom to Speak Up review to the overwhelming evidence on the bullying of whistleblowers and concluded: “Bullying in the NHS cannot be allowed to continue. Quite apart from the unacceptable impact on victims, bullying is a safety issue if it deters people from speaking up”.

The willingness of doctors to raise concerns declines from the start of training. The 2013 General Medical Council annual survey of doctors in training found that doctors starting their training posts were more likely to raise concerns about patient safety compared with those whose training is coming to an end.

The survey also found that doctors who are nearer to the start of a specialty or GP training programme are more likely to raise concerns than those nearer to the end of the programme. Evidence suggests bullying is a factor.

Witnessing versus reporting

The proportion of NHS staff “witnessing potentially harmful errors, near misses or incidents in the last month” has been stable for the last six years but the proportion who actually reported them has fallen since 2011. The reason for this is unclear.

Coincidentally the reported bullying levels significantly increased in 2012 – precisely the year reporting levels fell (Table 1). We should be wary of equating coincidence with correlation but the comparison certainly invites further exploration.

Table 1. Witnessing and reporting of accidents

 Percentage of staff witnessing potentially harmful errors, near misses or incidents in last monthPercentage of staff reporting errors, near misses or incidents witnessed inlast monthPercentage of staff experiencing harassment, bullying or abuse from staff in last 12 months*

*This question changed slightly in 2012 [QUERY: CHANGED TO WHAT??]. Source: NHS staff surveys 2009-2014

The proportion of staff saying they would feel safe when raising concerns has not improved since the 2013 Francis report was published. Between a quarter and a third of staff remain unable to say they felt safe raising concerns. While some trusts are making real improvements, overall the national staff survey data shows that this is not the case overall (Table 2).

Table 2. Would you feel safe raising your concern?

 Yes (%)No (%)Don’t know (%)
2014*           701030

*2014 question changed to “Would you feel safe raising concerns about unsafe clinical practice?”. Source: NHS staff surveys 2012-2014

Disruptive behaviour

A decade ago, Alan H Rosenstein considered the role of human factors and their effect on patient safety and clinical outcomes in US healthcare. He concluded that: “disruptive behaviours increased levels of stress and frustration, which impaired concentration, impeded communication flow, and adversely affected staff relationships and team collaboration. These events were perceived to increase the likelihood of medical errors and adverse events and to compromise patient safety and quality of care.”

A substantial body of data attributes medical errors to interactions among hospital workers. Rosenstein and O’Daniel reported a strong correlation in the the US between disruptive behaviours and the occurrence of adverse events (67 per cent), the occurrence of medical errors (71 per cent), compromises in patient safety (51 per cent), and compromises in quality (71 per cent).

In total, 27 per cent of those surveyed felt that disruptive behaviour is a contributing factor to patient mortality, and 18 per cent reported being aware of a specific adverse event that occurred directly as a result of disruptive behaviours.

These results supported the work of the US Joint Commission in its root cause analysis of sentinel events; it was found that nearly 70 per cent of the events could be traced back to a communication problem.

Behaviours that Undermine a Culture of Safety, the Joint Commission Sentinel Event Alert published in July 2008, also referenced a survey by the Institute for Safe Medication Practices, which found that 40 per cent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. It concluded that “all intimidating and disruptive behaviours are unprofessional and should not be tolerated”.

‘Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork and cuts off communication’

Lucian Leape’s 2012 seminal articles about disrespect in US healthcare summed up the evidence thus: “Disrespect 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.”

He adds: “Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfilment in work for all healthcare workers and contributes to turnover of highly qualified staff. Disrespectful behaviour is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture.

Time for change

We know what the prime drivers of bullying are. A major recent UK literature review concluded there are “higher levels of bullying in times of organisational change, in hierarchal organisations, in the presence of destructive leadership styles, and where bullying goes unchecked through lack of disciplinary action.”

At a time when 22 per cent of the entire NHS workforce consistently reports being bullied, when it rises to much higher levels in some NHS organisations, and when we know this adversely impacts on patient care, is it not time for a national NHS strategy to address this as a priority?

The late great Aidan Halligan understood this with his pioneering work on bullying and patient safety. Some individual trusts have done excellent similar work to reduce bullying, leading from the very top of the organisation. But nationally, and in too many other trusts, we remain in denial about the scale and impact of bullying on patient care and safety. 

We have a piecemeal approach, which often depends on a CQC inspection, rather than tackling bullying being a natural part of good management, governance and a patient safety culture. It’s surely time for a fresh approach?

Roger Kline is research fellow at Middlesex University Business School.