An educational intervention to tackle NHS bullying: early results and experiences

Within the UK, surveys of healthcare staff in 2013 and 2014 indicate that almost a quarter have witnessed or experienced bullying. Bullying is defined as “offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power through means that undermine, humiliate, denigrate or injure the recipient”.

It has detrimental effects on an employee’s physical and mental health, employee performance and patient care and costs organisations up to £13.75bn.

Several studies have highlighted the importance of tackling this important problem but few have described the type or efficacy of interventions.  

‘We believe that our work is unique in being a large scale educational intervention to tackling bullying in the workplace’

Our organisation was identified as having bullying issues in early 2014 following a Care Quality Commission visit, which were later confirmed by an independent Advisory, Conciliation and Arbitration Service report. Within six months of the CQC visit, a major overhaul of our senior management structure took place.

• Comment: Changing the culture of bullying in the NHS

An antibullying group was established under the leadership of the chief executive with membership from nursing and medical directors, union representatives, occupational health, human resources and a patient representative. Furthermore, an anti bullying ambassador was appointed, to lead and champion the success of any corrective measures.

This was in keeping with the recommendation that organisations should appoint a “well-respected peer, who firmly believes in the project and has the leadership and communication skills to make it happen”.

At our organisation, the director of medical education, who had knowledge of tackling bullying and harassment issues among doctors, was appointed to the position. The antibullying ambassador was provided with time and additional resources, including a designated administrator and a human resources manager, to assist in accomplishing the tasks.

A professionalism and culture transformation (PACT) academy was launched under the auspices of the antibullying ambassador to address the bullying issue. This was widely publicised in the local press and within the organisation to provide visibility and demonstrate commitment. The PACT academy established an educational intervention workshop for all members of the organisation.

This is in line with published work by Rowenstein et al who have highlighted the importance of an educational intervention for all hospital employees to raise awareness and produce change in the culture.

More than 2,000 members have attended the workshop with excellent feedback. Below, we present the mission of our educational intervention and recommendations for delivering such a programme (see Table 1).

Description of educational intervention

A spectrum of negative behaviours can occur in the workplace, including bullying. If not challenged, low level unprofessional behaviour can evolve into more serious behavioural concerns and bullying.

Hence, it is important to respond to all unprofessional behaviours and embed professionalism for a cultural transformation to occur within an organisation.

This was the goal of the educational workshop, which consisted of a 90 minute interactive session, including small group exercises, case studies and videos depicting bullying and unprofessional behaviour in the workplace. The key objectives were to ensure that staff understood professionalism and its context, learnt how to identify, raise and respond to concerns of bullying in the workplace.

The audience was limited to 15 employees with a diverse range of clinical and non-clinical duties.

’A patient described her inpatient experience when she saw the impact of horizontal nurse to nurse bullying on care’

The small group exercises focused on creating a checklist of professional behaviours that one would wish to see in the workplace. This was linked to the newly created behaviours charter for the organisation with a list of behavioural “do’s and dont’s”. Supplementing the discussion was a group exercise of the impact of micro cultures on the wider organisational culture.

A video depiction of workplace stress and target driven culture causing bullying behaviour to manifest between two individuals was shared. This was followed by an analysis of the behaviours witnessed, underlying reasons and strategies for responding to them.

Case studies depicting bystander reluctance to intervene was discussed at some length.

A key element of the workshop was an interview with a patient who described her inpatient experience when she saw the impact of horizontal nurse to nurse bullying on her and her fellow patients’ care. She also described undermining conversations and bickering between staff (clinical and non-clinical staff) who used workload pressures as an excuse to shout at patients.

A discussion of key highlights from the patient conversation was woven into a discussion about stress and unprofessionalism.

Organisational changes to respond to bullying were shared including the adoption of a zero tolerance policy, a new behaviours charter, a new online reporting tool and a staff advice helpline; the overall change from a financial/target driven culture to a patient focused culture was also discussed. The audience were appealed to asking for volunteers to become local “professionalism champions” to highlight the need and value of staff empowerment.

The workshop concluded with each participant signing a challenge to participate in the professionalism and culture transformation and sharing one positive change they would make in their own environment when they left the workshop. These “pacts” or pledges were emailed to the delegates three months later to remind them of their pledge and encourage them to continue with the good work they had commenced.

Delegates completed a pre and post-workshop questionnaire which addressed their confidence levels towards identifying, raising and responding to concerns of bullying and of their understanding of professionalism. Feedback on the session and facilitator’s skills were also collected.

We believe that our work is unique in being a large scale educational intervention to tackling bullying in the workplace and has shown significant immediate improvements in employees’ perceptions of this important problem. Our experiences of delivering this intervention can offer useful insights into how to design a large scale educational intervention for tackling bullying in the NHS and beyond.

Understanding of professionalism

The workshop was designed to address the issues of bullying within the wider spectrum of unprofessionalism. Organisations with behavioural problems have used a developmental approach focussed on the creation of a code of conduct highlighting professionalism.

It is important to reinforce these positive values and we used our organisation’s newly created code of conduct incorporating professionalism in our discussions during the workshop. Mccarthy and Barker evaluated a guide to deal with workplace bullying in Australia and found that majority of staff for whom it was written, had not even heard of the document.

Merely writing a code of conduct is not sufficient, it needs to be communicated to employees.

Our results show a significant improvement in the self-reported confidence levels of understanding of professionalism and its context and we believe that this will contribute effectively to the cultural change in our organisation.

Identifying and understanding bullying issues

Using the video of a hostile telephone conversation between a hospital manager and a ward staff nurse, we discussed the enabling, motivating and precipitating factors for bullying.

‘By using a holistic approach to the issue of bullying, we suggest that given the right factors, anyone can become a bully’

Employees’ common perception is that there are certain key individuals in the organisation who are the “bullies” and by sacking them, the organisation’s problems can be alleviated. By using a holistic approach to the issue of bullying, we suggest that given the right factors, anyone can become a bully.

Employees also believe that unprofessional behaviour and bullying manifest as a “logical adaptation to a stressed workplace”. This is challenged during the workshop.

The academy’s wider work around team training and cultural transformation is shared with participants highlighting areas of positive culture in our own organisation in supposedly “high stress” areas, such as our theatres, to demonstrate that stress does not necessarily equate with unprofessionalism and negative behaviours.

Our delegates showed a significant improvement in their ability to identify and understand bullying issues. Increasing delegates’ self-awareness of attitudes and a better understanding of unprofessional and bullying behaviours are cited as potential mechanisms for change.

We believe that educational interventions to tackle bullying issues should address common myths and fallacies of employees. Using Lewin’s model of learning, one needs to unfreeze misconceptions before freezing in new models of thinking and approach and we believe that our workshop has provided the stimulus for this change to occur.

Raising concerns

Resch and Schubinski suggest that organisations prefer to deny the existence of a bullying culture and suggest that the negative image of having a problem may be needed for a positive change to happen. We highlight this approach in the workshop to demonstrate that there is no “shame” with being known as a bullying organisation and that acknowledgement is the first step to recovery.

Against this backdrop, we present a case study of unprofessional behaviour and how colleagues could approach the situation, underlying the importance of raising concerns. Our results suggest that our approach was successful and provided an increased confidence among participants to raise concerns. 

‘Acknowledgement is the first step to recovery’

Bystander interventions is believed to be a powerful intervention in preventing and tackling bullying. Despite this, bystanders demonstrate apathy and do not feel able to intervene.

Rayner and Mc Ivor recommend that all staff should challenge unprofessional behaviour and believe that this is a key intervention to prevent bullying in an organisation. Considerable time in the workshop is devoted to this topic and a collective approach to tackling bullying is discussed to reinforce the concept of strength in unity.

Evidence suggests that a voluntary peer group (local professionalism champions) support system could support bystander interventions and through the platform of our workshop we are actively recruiting to the roles of the local professionalism champions who we believe can support bystanders in this important task.

Tackling concerns

Evidence suggests that within organisations with low levels of bullying, the focus should be on complaints procedure and for those with high levels of bullying, the focus should be on prevention. We, therefore, believe that our workshop should not only focus on tackling concerns of bullying but also be preventative in nipping unprofessional behaviours in the bud.

The case studies of bullying we use in our workshop encompass overt examples of bullying to support examples of unprofessionalism.

All case studies used in the workshop were based on real life examples. To engage a clinical and non-clinical audience, scenarios were drawn from both backgrounds.

This resulted in an immediate recognition and ownership of the issues raised and generated lively discussion among participants. Other studies have highlighted that contextual relevance is important and that scenarios should be tailored to local settings for an intervention to be successful.

’Defusing tension and anger by conflict resolution resulted in positive changes in the team’s environment’

Conflict management training has been recommended as an intervention for workplace bullying. In our workshop, we share our experiences of conducting a team exercise for nurses in an acute medical setting, where defusing tension and anger by conflict resolution resulted in positive changes in the team’s environment.

Whilst we do not offer any specific role play or opportunities to practice due to time constraints, we believe that our participants felt that this was an important part of the workshop judging from the number of free hand feedback comments requesting more time for practicing these skills.

Peers are best placed to raise and tackle concerns of unprofessionalism and bullying in the workplace as evidence suggests that feedback received from a colleague is better received and acted upon than from a superior. We have successfully enrolled 40 individuals to the roles of the professionalism champions and have provided specific training for 25 of these individuals to undertake the role which has included mediation and conflict resolution skills.

Conclusion

Good organisations tackling bullying should focus not only on short term curative measures but also preventative strategies such as educational interventions to sustain long term change with an expectation for all employees to attend. We believe that by focussing our workshop on long term goals of professionalism and culture change.

We have achieved a buy in from the organisation for a long term approach to the issue of bullying in the workplace.

The skill level of the trainers delivering the workshop has been key to the success of this programme so far and is recognised as key factors for active learning and role playing sessions. The programme was conceptualised by the corresponding author, the Anti Bullying Ambassador, who has since trained four other educators to deliver the programme.

The majority of the workshop has been delivered by the same individual that has ensured a high degree of reliability and consistency of educational delivery. In addition, the scores of all five trainers are constantly monitored and shared with the educators to ensure that real time feedback is provided to maintain the high standards required for course delivery.

We believe that the positive feedback of workshop was due to the authenticity of the situations we created for the discussion and we therefore strongly recommend that detailed background research is performed before an educational intervention of this nature is set up.

Studies suggest that a critical mass of employees are required to undergo training and those who need to train are least likely to attend, especially if it is voluntary training. We have been fortunate in having a good uptake of the programme with full booking of our workshops, some going on for the next six months with only a small number of cancellations. Mandatory status of the workshop has ensured in consistent attendance at the course but this has been reinforced at frequent intervals by senior management leaders.

The buy in of the chief executive has been crucial to the success of the programme. It is noteworthy that the first PACT workshop in the organisation was delivered to the chief executive, chairman, chief medical officer, executive and non-executive directors of the organisation.

We acknowledge that the biggest challenge for any educational intervention addressing bullying, including ours, will be to evaluate its impact. In order to show a reduction of bullying, one needs to know the baseline bullying rate. Under reporting is the norm and therefore is unlikely to be the best way of evaluating the success of interventions.

Surrogate outcomes in form of absenteeism rate, turnover rate, stress surveys, staff surveys, patient complaints and visits to occupational health by staff may all be used.

A CQC visit to our organisation recently has confirmed positive changes to the organisational culture. Although these are anecdotal improvements, we are confident that we will be able to demonstrate improvements through other instruments in our organisation in the months and years to come.

Makani Purva is anti bullying ambassador, Hull and East Yorkshire Hospitals Trust