If there’s one thing that Anthea Mowat hates even more than bullying, it’s the assumption that bullying is inevitable.
‘When I meet people who are being bullied, my anger doubles when I am told it is part of the culture. “Par for the course.” Only to be expected in a stressful and competitive world.’
While it might, unfortunately, be part of medical culture, that doesn’t mean the culture is not capable of being changed.
Dr Mowat, the BMA representative body chair, was speaking at the Tackling Undermining and Bullying conference in Birmingham, jointly organised by the RCOG (Royal College of Obstetricians and Gynaecologists) and the RCSEd (Royal College of Surgeons of Edinburgh) earlier this month.
For these specialties to be organising the conference was itself significant, given that, as RCOG vice president Alison Wright pointed out, there was a higher incidence of bullying and harassment reported by trainees in her own specialty than in any other, according to the GMC trainees survey. Surgery came second.
Duty to challenge
If there was one overwhelming message from the day, which included some disturbing accounts and statistics of the impact of bullying, it is that not only it can be challenged, but it must be challenged, for the sake of those both employed and treated by the health service.
Dr Mowat (pictured below) said a fifth of doctors had suffered workplace bullying or harassment, and the incidence was three times higher in the medical profession than the wider economy.
‘If this were any other kind of occupational disease, affecting the workforce on this scale, we would have tackled it by now.’
She said the BMA’s bullying and harassment project, set up last year, had found three major factors behind bullying.
These were workload pressure – where bullying was often passed ‘down the line’ from a harassed chief executive; hierarchy, in that the greater distance is created between people, the less they may think of their impact on each other, and silence, where incidents are not reported, perhaps through a fear of reprisal or that nothing would be achieved.
‘It is so important to say that explaining is not the same as excusing,’ she said. ‘But it is useful to explain if we can.’
Perhaps the most compelling argument against this behaviour – to paraphrase Bill Clinton – is that ‘it’s about the patients, stupid’ – except Chris Turner, who spoke movingly of the impact of rudeness and bullying on patient care probably wouldn’t call you ‘stupid’.
The emergency medicine consultant from Coventry is one of the leaders of the ‘Civility Saves Lives’ campaign, which seeks to highlight the abundant evidence base for the impact of rudeness on patient care.
Dr Turner, whom we recently profiled, began with a story – true, with some details changed – of a case in which a swab was left in a patient’s abdomen following a series of incidents in which a scrub nurse had felt bullied and undermined.
The outcome of the case had been that the nurse was sent for retraining. But was that the correct, or the only possible outcome?
The background was that the surgeon, himself unhappy at being pressured into taking on an extra case, had spoken aggressively to the nurse, upsetting him so much that he had to temporarily leave the theatre.
Dr Turner said that by not dealing with the surgeon’s behaviour, as a likely contributory factor, ‘I think we missed the point and we stopped ourselves becoming better'.
While it’s reasonable to say the accident could still have happened in the most relaxed of circumstances, it is no longer reasonable to deny the evidence base which links rude behaviour to poorer patient outcomes.
Being rude is not the same as bullying, although it can be a component of bullying behaviour, and it’s not difficult to argue that countering an atmosphere of casual, dehumanising disrespect would help tackle the bullying culture too.
Effect on thought
Being the object of rudeness is associated with a 60 per cent decrease in cognitive ability, he said. It leads to nurses making more calculation errors.
It has a direct impact on hand-eye coordination. Recipients are less likely to help a person in distress in the immediate aftermath – ‘we strip them of their humanity’. Those who witness it, rather than being somehow chided and refocused by the example, also experience a drop in performance.
The point is, Dr Turner has the numbers to back up his case that incivility is bad, very bad, for patient safety. It is, he acknowledges, a ‘new science’ – 23 papers published between 1996 and 2001, 1,700 between 2011 and 2016 – but a science with enough of a research base from which to draw some clear conclusions.
Now that we know just how harmful these behaviours are, Dr Turner says there is a ‘wonderful opportunity for us to move forward to create environments that respect and value those who work with us’.
To create such environments, it is vital that doctors must be supported in reporting incidents. They have a vigorous defender in Henrietta Hughes, the first national guardian for the NHS.
Dr Hughes provides leadership, training and advice for the freedom to speak up guardians which can now be found in every English NHS trust. They are the product of Sir Robert Francis’ Freedom to Speak Up Review which followed the Mid-Staffordshire scandal.
She said the guardians aimed to support people who raised concerns – more than half of which are about bullying and harassment – through the whole process.
Dr Hughes said there was a correlation between NHS organisations which performed well and those which were perceived give weight to the issue.
When asked whether ‘speaking up is taken seriously in my organisation’, in a survey published in the national guardian’s annual report, 84 per cent of respondents from trusts with an outstanding rating from the CQC said yes. In organisations rated inadequate by the CQC, this fell to 36 per cent.
One such trust the CQC rate as outstanding is Northumbria Healthcare NHS Foundation Trust. When its chief executive, Jim Mackey, rose to speak, it’s fair to say there were some murmurings of unease in a session otherwise dominated by consensus.
The issue was not with Northumbria, but NHS Improvement, where until recently Mr Mackey was seconded as chief executive. This was a conference with ‘harassment’ in the title, and there are plenty of doctors and senior managers who have felt harassed by the pressure put upon them by NHS Improvement to meet financial targets which they have found unreachable.
But Mr Mackey focused on Northumbria, and gave a frank account of an organisation which had transformed its staff survey results from ‘terrible’ to among the best in the NHS.
He described bullying as a ‘tricky issue’, and not necessarily within the competence of all senior staff.
‘You should not assume we all know what to do with bullying. A lot of managers and leaders are really quite stressed with the concept of having to deal with bullying situations. When you’re raising things, you’re absolutely right to raise them but understand this is really tricky stuff. People are really nervous about it, at least not making things worse.’
While many of those who spoke at the conference, including Mr Mackey, said that those who bully have to face consequences – indeed chief medical officer for Scotland Catherine Calderwood asked whether it should be treated in the same way as those not competent at their jobs, with all the potential sanctions this implies – Mr Mackey said it was also important to remember that those who bully do not always realise that they are bullying.
He said: ‘Personally I’ve had to deal with senior clinicians who had been bullying people and certainly there were those who were completely oblivious to it.’
It echoed earlier comments by RCSEd president Michael Lavelle-Jones, who said the most visited page on his own college’s web resources on the subject was entitled ‘Are you a bully?’ It’s not in all cases a rhetorical question.
Mr Mackey said everyone should be aware of how they were perceived, whatever their intention. Shorter, and electronic, forms of communication were perhaps most likely to misjudge tone.
‘I personally detest social media… it was bad enough with email… just missing a couple of words out can change the impact at the other end, and I’m now working very hard to be more careful with my very short emails sent at 5 o’clock in the morning to make sure that no-one at the other end feels intimidated and under too much pressure.’
The need for awareness to run through an institution was also stressed by Malcolm Wright, the chief executive of NHS Grampian who visited Australia to study its approach to the problem.
It is a country where high rates of sexual harassment have been reported in the past, but he said that at St George Hospital in Sydney there had been a concerted effort to ‘name it, to talk about bullying and harassment’ – more so than happened in the UK, he said.
At St George, there were explicit statements of what was acceptable, and what was unacceptable. In the latter column, we find not only passive-aggressive behaviour, but the kind of passive approach where people take a huge amount of interest in their tablets during meetings and very little in their colleagues who are trying to speak.
There is perhaps within the medical mythology not just a belief that rudeness is inevitable but that it is part of the eccentric charm of the brilliant clinician.
Lancelot Spratt, possibly the most disinterred man in history, was once again pulled up from his grave in order to be re-killed.
Dr Hughes was one of several attending who gave short shrift to the assumption that some are so talented that they have licence to behave badly to others a stereotype particularly associated with surgeons.
The mythology is such… that there are some people whose surgical skills are so unique and special that we will tolerate their poor conduct. That isn’t how the All Blacks recruit. The All Blacks have… a “no arseholes” rule and it hasn’t done any harm to their performance.’
And for a moment, the NHS had a new mission statement, set in neon lights above every hospital and GP surgery in the land.
Read Dr Mowat’s presentation to the conference
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