Bullying part II: Speaking truth to power is good (but may be dangerous in the NHS)
Roger Kline, 14 June 2013
Bullying in the NHS is widespread, and more so than in other parts of the economy. Almost one in four respondents in the 2012 NHS Staff Survey said they had experienced bullying, harassment or abuse from a manager, team leader or other colleague during the previous year.
That is obviously bad for them, but the impact on patient safety could be just as serious if fear of the personal consequences of raising concerns makes staff reluctant to do so.
As Dean Royles, the head of NHS Employers, has explained: "Robust staff engagement and encouraging a culture of openness and trust are key in addressing under-reporting. Confidence to report bullying is directly related to confidence to report workplace concerns." ('Trust and culture change are essential to tackle bullying', Nursing Times, 12 July, 2011).
This might help to explain one of the anomalous findings of the 2012 NHS staff survey, which showed that while the percentage of respondents who said they had witnessed potentially harmful errors, near misses or incidents in the previous month was unchanged compared to 2011, at 30%, the proportion of staff reporting them fell by 6%.
There is probably no single explanation for this, but overall it seems that not enough staff felt sufficient confidence in the balance between potentially positive effects for patients and negative effects for their careers of raising concerns, and the 2012 staff survey shed light on both sides of the issue.
It showed that only just over half (55%) would feel confident that their organisation would address concerns if they raised them, and less than half (42%) agreed that their organisation gives staff feedback about changes made in response to reported errors, near misses and incidents.
A small but significant minority - 14% - also felt that reporting of errors would lead to punishment or blaming of those involved.
If you add the fear of the negative to the lack of confidence in the positive consequences of raising concerns, it is clear there is a serious problem.
Over a decade ago the public inquiry report into child heart surgery deaths at Bristol Royal Infirmary concluded: "There is a real fear among junior staff (particularly among junior doctors and nurses) that to comment on colleagues, particularly consultants, is to endanger their future work prospects. The junior needs a reference and a recommendation; nurses want to keep their jobs. This is a powerful motive for keeping quiet."
Since Bristol, survey after survey of healthcare staff has confirmed the widespread fear of the consequences of raising concerns, and the fact that the majority of staff even have no idea if anything is done when they do stick their neck out and report a concern.
Academic research has underpinned numerous survey results. One report concluded: "Reprisal for whistleblowing remains a major concern for nurses. Future research should concentrate on developing an environment where nurses feel able to report incidents safely. Confidentiality should be given priority, thereby reducing the fear of reprisal or future repercussions.” (Whitehead B, Barker D (2010): 'Does the risk of reprisal prevent nurses in the NHS from blowing the whistle on bad practice?', Nursing Times, 106: 43, 12-15.)
Research in 2010 for the Nursing and Midwifery Council, the regulator, found the fear of being victimised after blowing the whistle remained a major barrier to nurses and midwives reporting problems. The NMC surveyed 56 organisations and 395 nurses. Many expressed fears about the implications for individuals of raising concerns, particularly the risk of victimisation, being stigmatised as a “troublemaker”, bullying or intimidation. (Ben Clover, 'Fear of victimisation stops nurses whistleblowing, says NMC research', Nursing Times, 10 August 2010).
That fear is still there. One writer noted recently in the British Medical Journal: "One could forgive an outsider’s bemusement at how it is that a modest number of NHS managers succeeded in creating such a hostile environment that only 11% of doctors have confidence in whistleblowing protection. If the majority of the powerful in medicine (which includes doctors as well as managers) believed that whistleblowers were a gift rather than a curse to the profession then the culture of fear would be overthrown and the problem would cease to exist."
The evidence is overwhelming. If we want staff to raise concerns they need to know they will not be punished for doing so, while patients will benefit because the organisation will learn from them and staff who make mistakes will be treated justly.
It is time we made the prevention of bullying a top priority for patients as well as staff.
This is Part 2 of a blog entitled “Bullying: the silent epidemic in the NHS". For Part 1, go here.
For advice about how NHS staff can protect their right to exercise their duty of care, see our special handbook and advice notes here.