Bullying and undermining in the NHS: A threat to staff and patient safety

NHS doctor Mr David Riding explains how bullying and undermining represent a threat to both staff and patients which must be tackled if we are to truly become a “caring profession”

In 2021 the NHS Staff Survey found that almost one in five employees had experienced an episode of bullying, undermining or harassment from a colleague within the preceding year. This equates to around a quarter of a million people subjected to oppressive behaviour in their workplace. This should give us all cause for reflection.

To understand the impact of this behaviour, it is essential to appreciate the following: an incident of bullying or undermining has occurred if an individual perceives that it has. This can be difficult, particularly when considered within usual jurisprudence notions of “innocent until proven guilty.” We must consider bullying and undermining in different terms, and acknowledge that if an individual perceives themselves to have been victimised, then their ability to deliver high quality healthcare is severely compromised, whatever the intention of the person responsible. Data from the GMC survey shows that trainees who believe they have been bullied rate all aspects of their educational experience — quality of feedback, quality of induction, clinical supervision, regional teaching, courses etc — lower than those who have not.

I and my colleagues at the Royal College of Surgeons of Edinburgh have been campaigning to eliminate this behaviour from healthcare. Occasionally, we have faced hostility, with some surgeons believing that enduring oppressive behaviour is one of the many hurdles we must overcome to “prove our worth” as people able to cope with the demands of the profession. We might have been tempted to acquiesce, were it not for the fact that this behaviour is endured with more frequency and severity by ethnic minorities, women, or indeed anyone who deviates from the stereotype of a white, male, Type A autocrat.

For the persistent sceptic, the clear association between bullying, undermining and poor patient outcomes becomes difficult to reject. Indeed, if a particular treatment was associated with similarly egregious care, it would never reach patients. Anyone who has read the Francis Report into the harm done to patients at Mid-Staffordshire, or the Kirkup Report on poor maternity care at Morecambe Bay, or details of former breast surgeon Ian Paterson’s dangerous practice, will understand that oppressive behaviours and harmful working cultures shrouded the delivery of dangerous healthcare.

All NHS trusts have bullying and undermining policies to mitigate this behaviour, but the data shows that there is little confidence in their efficacy. Well-meaning staff feel intimidated and powerless to speak up, and trainees take solace from the characteristically transient nature of their placements to assume that “things will be better in the next job, I’ll just keep my head down.” Patients’ families often struggle for years to remove the shroud, revealing the danger that often lies in plain sight behind the hospital doors.

In this context, the idea of “the caring profession” seems dissonant. Why do individuals behave like this if they are apparently working to improve quality of life of their patients? There are internal factors based not only around ego and displays of power, but also lack of confidence, poor self-esteem and situational misreading – particularly within teams with significant generational and cultural diversity. External drivers of clinical and management pressures, problems at home, and propagating behaviours learned in their own training may also be responsible. Importantly, qualitative studies have shown that as work pressures increase, particularly around times when extra responsibility is acquired – eg the transition from medical student to Foundation doctor – an empathy decline is induced even in those who previously considered themselves to have high empathic ability. As healthcare workers, we need to be aware of this phenomenon, and mitigate it by reflecting on our behaviour.

Combating undermining and bullying is hard. There are no easy options, there are poor quality reporting systems, and reputations for “being difficult” are easily acquired and hard to lose. Nonetheless, we have a moral duty to defend ourselves, our colleagues and our patients. Analogies to clinical practice are useful: document everything, stay professional, stick to the facts, and find an ally who you can discuss the problem with. Try to manage the issue within your department, but have a low threshold for going through the Trust – each has a Freedom to Speak Up Guardian – to your trade union, or to the Care Quality Commission. Many medical Royal Colleges have useful resources and are able to advise confidentially.

All of this is difficult. As a group of workers held in high esteem by the public, we might instinctively draw back from considering that there are times when our poor behaviour is threatening patient care. As exemplars of good behaviour, we might find it very difficult to know what to do if we are victimised. However, by measuring the scale of the problem, by defining standards of behaviour and its effect, and by stimulating conversations, we have at least begun to take our first steps towards changing the culture of healthcare for the benefit of our colleagues and patients.

Mr David Riding is a Specialty Registrar in Vascular Surgery at the Manchester University NHS Foundation Trust and works to reduce bullying cultures as part of the Royal College of Surgeons of Edinburgh Bullying and Undermining Group.