Is there a crisis of bullying in the NHS?
There is considerable commentary in the press and in general about a culture of bullying within the NHS. A recent Independent ¹ headline stated NHS bosses would be sacked if they failed to stamp out ‘alarming’ rates of bullying of hospital staff. The article claimed that “hundreds of thousands of NHS workers are suffering bullying….”. These headlines and statements are fairly typical examples of coverage and perception of this issue within the media, wider public, unions and indeed staff.
Why is this perception of a crisis of bullying so widely accepted?
I want to make a closer examination of this, and the data and perceptions this phenomenon is based on. For the purposes of this article, I am focusing solely on the issue of staff/colleague bullying, and I am not addressing the issues of patient, relatives and public harassment, bullying or abuse directed towards NHS staff. That is for another time.
This is an issue of national importance. As an extremely serious concern, it must be debated in a logical and reasoned manner. Sweeping statements and exaggerated comments do not help or support the victims of bullying or NHS employers to address the issue.
For the record, I do believe that there is bullying in the NHS. My question is whether it is as endemic as the widely-held perception would suggest? Unfortunately, bullying in the workplace is a reality in every sector of the economy. ACAS estimated in 2015 that workplace bullying costs the UK economy £18 billion annually². Other research indicates the costs to the economy could be double the ACAS figure³. Unfortunately, the UK has failed to tackle the issue adequately and continues to refuse to legislate as most other countries in Europe have done. In the absence of a legal definition of bullying and no legal requirement to deal with it overall, the national response is falling far short of what is needed.
There are a number of issues which contribute to the overall perception of bullying in the NHS which I wish to address. There is confusion on the nature and the definition of workplace bullying, the survey question posed to staff in the Survey Coordination Centre (SCC) managed survey and the interpretation of the statistics based on responses to this question.
Nature and definition of bullying:
The working definition of bullying in the UK is provided by ACAS⁴, but it must be understood that this is not a legal definition and there is no legal obligation upon an employer to accept it. This definition however has a major flaw in that it is a definition of ‘Bullying and Harassment’ and there is a considerable body of research which clearly states that bullying and harassment are two very separate issues for several reasons.
First, harassment is specifically directed at a person because of sex, race, disability, nationality, age, sexual orientation, religion or belief. Bullying can be directed at anyone for any reason. It is distinct as bullying as it is not predicated on membership of any unique group. Secondly, harassment can occur as an isolated incident or it can be repeated. Bullying always occurs as a repeated offence. Thirdly in the UK there are specific laws in place to protect victims of harassment, as harassment is a form of discrimination, but there is no law against workplace bullying.
I believe that the failure to legislate for bullying in the UK, combined with the synonymous use of the words ‘bullying’ and ‘harassment’ has led to a belief that the problem of bullying is greater than it is in reality.
Many instances of reported bullying are in fact harassment or affronts to dignity and respect, but they are not bullying. That is not to excuse such behaviour. All are unacceptable, but if one is to deal with bullying effectively, there must be a clear definition of what constitutes bullying and a recognition of the severe implications for the victim, as a result of repeated offensive, intimidating, malicious/insulting behaviour, or an abuse of power through means intended to undermine, humiliate, denigrate or injure the recipient.Many studies on victims of bullying suggest that physical and psychological symptoms can result from bullying. A 2003 survey conducted by the Workplace Bullying & Trauma Institute indicated that bullying caused a host of stress-related health issues ranging from “severe anxiety (76%), disrupted sleep (71%), loss of concentration (71%), PTSD (47%), clinical depression (39%) and panic attacks (32%). (as cited in Namie in 2003) ⁵. Ongoing research in more recent years has confirmed these symptoms as typical of an individual suffering bullying. There is no doubt that the impact of bullying is very serious.
A clear definition is required if one is to get accurate data as to the scale of the problem. I do not believe that is currently possible as bullying and harassment in the UK are effectively considered one and the same. The following table provides the working (not legally binding) UK ACAS definition and the Irish legal definition as a comparison.
ACAS Definition of Bullying and Harassment
Bullying and harassment means any unwanted behaviour that makes someone feel intimidated, degraded, humiliated or offended. It is not necessarily always obvious or apparent to others and may happen in the workplace without an employer's awareness. Bullying or harassment can be between two individuals or it may involve groups of people. It might be obvious, or it might be insidious. It may be persistent or an isolated incident. It can also occur in written communications, by phone or through email, not just face-to-face.
Irish legal definition of Bullying⁶
“Workplace Bullying is repeated inappropriate behaviour, direct or indirect, whether verbal, physical or otherwise, conducted by one or more persons against another or others, at the place of work and/or in the course of employment, which could reasonably be regarded as undermining the individual’s right to dignity at work.” Once off or isolated incidents will not be described as bullying. However, when the behaviour is systematic and ongoing it may be described as bullying. Bullying in the workplace can take different forms, such as:
• Social exclusion and isolation
• Damaging someone’s reputation by gossip or rumours
• Aggressive or obscene language
• Repeated requests with impossible tasks or targets
There are obvious and critical differences in the Irish legal definition which is similar to legislation in other EU member states. In Ireland, workplace bullying is considered a health and safety issue and the prevention of bullying falls under the remit of the Health and Safety Authority to ensure a safe working environment. There are clear codes of practice which employers are obliged to implement⁷.
I suspect that without a clear definition many claims of bullying in the UK, and including the NHS, are in fact not bullying. This does not mean that concerns raised more appropriately as harassment or affronts to dignity and respect are not to be treated seriously, but it does not constitute bullying.
It is this lack of clarity that is compounding the data collected on bullying and suggesting that the situation is worse than in reality. The National Guardian Office (NGO) have, in my opinion, further exacerbated the issue by instructing Freedom To Speak Up Guardians in the NHS to record and report all claims of bullying or harassment made by staff whether or not, when challenged, these in fact turn out to be bullying or harassment. A staff member only has to say “I am being bullied or harassed” regardless of the facts for the issue to recorded as bullying or harassment. The NGO further advises “…. that the terms should be interpreted broadly and that the focus should be on the perceptions of the individual bringing the case” ⁸. This a further example of a poor definition of the issues, their synonymous use and in my view does not help understand the real issue.
NHS Staff Survey – the question:
The following is the question posed to NHS staff in the annual survey on harassment, bullying and abuse. For the purposes of this article I am focusing on parts B and C, staff/colleague interactions⁹
It is on the basis of this question that the estimates of bullying in the NHS is primarily calculated. In the 2017 survey the SCC reported a key finding (KF26) that 24.3% of staff experienced harassment, bullying or abuse from staff in the last 12 months¹⁰. It is probably this key finding that is being used by some to suggest that hundreds of thousands of staff in NHS England are being bullied. It is important to deconstruct this statistic in terms of both the question asked and the response received.
As a survey question there is a fundamental flaw in that it asks about three concepts all of which are different. This is a further example of the conflation of the terms harassment and bullying and further complicated by the inclusion of a third term - ‘abuse’. These three terms are also open to interpretation by respondents so one does not really know what is actually being reported other than it is a report of negative and unacceptable behaviour in many forms. It cannot be determined from this question to what extent staff are being bullied.
The key finding of 24.3 % is also problematic as it is an average of the responses for both subsections B and C and across the entire scale. Any response from point 2 to point 5 on both scales is averaged to deliver the figure of 24.3%. So, a large series of questions remain unanswered. Are people being bullied, harassed or abused? How repetitive is this behaviour? There is no scale of severity, yet they are collated as one statistic. The question and key finding tell us something is going on, but it is all but impossible to say exactly what, and to what extent.
NHS Staff Survey – the interpretation of the response:
The statistics that surround this question are also interesting to deconstruct. 1.1 million staff were invited to complete the survey out of a population of 1.2 million NHS England staff. 487,277 responses were received giving a response rate of 45% according to the SCC. By my calculations this in fact 44% 487,227/1,100,000 = 44.29% and when rounded down = 44%. If the entire population of 1.2 million is included in the calculation the completion rate falls to 40.60% or when rounded up, 41%.
These figures tell us that there is a non-response bias in the survey result of between 55% and 59% - the staff who did not respond. The SCC would suggest that based on the sample size if would be reasonable to extrapolate that had a 100% response been attained the figure of 24.3% would have been sustained across the entire staff compliment. But we do not know this for certain. We do not know why the majority did not respond and we do not know what they would have said.
This figure of 24.3% equates to 118,396 of the respondents in the 2017 survey. It is this figure that when extrapolated to all staff that, I can only assume, led to the Independent suggesting that hundreds of thousands of staff are being bullied in the NHS.
Would it not also be reasonable to suggest that not all of the responses were identifying bullying as there were three distinct concepts within the question? I am sure that there were as many concerns of harassment and/or abuse being recorded in this response. Quite possibly only a third were reporting bullying which would be 8.1% or approximately 40,000 staff. This, even when doubled is nowhere near the claim of hundreds of thousands of staff being bullied. The point is we do not know. Maybe all the responses related to harassment and abuse and not bullying, unlikely as that may be, but we do not know.
Not only is the question in my opinion flawed, there are many ways to interpret the data, which means we do not know the extent or the seriousness of the problem and that leaves us with some of the unhelpful statements that surround the issue.
Bullying in the workplace is a serious issue. It is extremely debilitating for victims and it will most certainly impair an individual’s performance. In the critical area of health care this must be addressed. It must, however, be addressed in the light of hard facts and understanding and not the nebulous position we now find ourselves in.
There is a problem with bullying in the NHS but is it a phenomenon of the economy as a whole. The NHS due to the current pressure it operates under, may seem to have a bigger problem than other sectors. That may well be the case, but right now the data in my view does not support the claim that hundreds of thousands are being bullied.
More hard data and a level, rational analysis and discussion is required so that proper and targeted action can be taken.
Dr Simon Mac Rory
The Guardian Service Ltd.
Independent: 2018. NHS bosses will be sacked if they fail to stamp out 'alarming' bullying of hospital staff
https://www.independent.co.uk/news/uk/politics/nhs-staff-bullying-abuse-health-workers-uk-government-crackdown-a8538166.html - Accessed 22nd February 2019
Business Reporter: 2015. Workplace bullying costs economy £18 billion, ACAS claims
https://www.business-reporter.co.uk/2015/11/16/workplace-bullying-costs-economy-18-billion-acas-claims/#gsc.tab=0 – Accessed 22nd February 2019
Perez. M. A. (2012). Workplace Bullying: See no Evil, Hear no Evil, Speak no Evil (Is there a need to legislate for workplace bullying in the UK?) Doctorate of Business Administration. Document 5. United Kingdom: Nottingham Business School, Nottingham Trent University
ACAS. 2016: Bullying and Harassment
http://www.acas.org.uk/index.aspx?articleid=1864 - Accessed 22nd February 2019
Namie, G. (2003). Workplace Bullying: Escalated incivility. Ivey Business journal.
November/December. pp. 1-6
Irish Legal News: 2017: Bullying in the Workplace.
Accessed 22nd February 2019
HSA: 2018: Prevention of Bullying – Codes of Practice
Accessed 22nd February 2019
NGO: 2018: Guidance for Freedom to Speak Up Guardians Recording Cases and Reporting Data
https://www.cqc.org.uk/sites/default/files/20180719%20Guidance%20on%20Recording_0.pdf - Accessed 22nd February 2019
NHS Staff Surveys. 2018: Core Questionnaire
Accessed 22nd February 2019
Survey Coordination Centre. 2018: NHS Survey 2017. National Briefing.
Accessed 22nd February 2019