Bullying, healthcare and human factors

Bullying is very topical. Every time it’s discussed on TV or the radio, people queue up to say ‘yes, it happened to me’. But surely it’s something we grow out of as we enter the world of work? I’m not a psychologist, but I’d guess that school bullies did so because of some issues in their own lives or personal make-up.

It’s logical to assume that some of those same people are now working in the NHS. Maybe you’ve met them. But is bullying a big problem for the NHS? Surely these lone bullies are so rare that it’s not really of interest to the organisation as a whole?

When the Healthcare Commission closed down in 2009 its chair, Sir Ian Kennedy, left us with this thought: ‘One thing that worries me more than anything else in the NHS is bullying...We’re talking about something that is permeating the delivery of care in the NHS.’ In the same week as Sir Ian made his comments, the HSJ reported staff surveys showing over one in ten in the NHS had experienced bullying.

So what? Does it really matter to safety? You bet it does. Sir Ian commented that the chief nurse at Bristol Royal Infirmary had been ‘bullying everybody’.

A regular feature in accident reports across all safety critical industries is an inability of people to speak up or an inability to be heard. From my own experience of observing interactions in a number of industries, I can assure you that this inability isn’t something that develops instantly, it has to be developed over time. I’d like to suggest that the problem isn’t so much the lone bully with a ‘personal issue’, but more likely the passionate, driven individual or team.  

We need people with passion and strong conviction. These people often become the leaders, either formally or often informally in the ‘office hierarchy’, and are often driven by single-mindedness or purpose, pursuing a target with determination. There’s nothing wrong with that, but that drive seems, on occasion, to become like an express train: fixed on rails, going faster and with an inertia that makes it impossible change its direction. Speak up at your peril – at best you’ll be unheard or simply not be able to be heard. At worst, you’ll be knocked flying. You won’t go near that track again.

A good leader needs drive and determination, and a passion for what’s right. But they also desperately need that good, non-technical skill: situational awareness (SA) – knowing the big picture, often described as ‘What? So What? Now What?’ In other words, a good leader needs to know what’s happening (and how often in recent public scandals has that not been the case?), what it means to their organisation and what needs to now happen as a result of that information. And good situational awareness requires a steady flow of information – up, down and across the organisation. This of course requires a culture of openness in communication, and that is created by those in power.

Notice I use the phrase ‘those in power’. Because those with power aren’t always the ones in charge. Often power can come from knowing more than those around you. It can be from being ‘a consultant’, or ‘a doctor’, or it can come from being on the unit longer than those around you. People look up to you, but you’re only as effective as your situational awareness and this is reduced if those around you – including those ‘less knowledgeable’ or ‘less experienced’ than you – aren’t sharing information or perspectives.

All of you reading this have some form of power base. And you all have a leadership role, even if it’s only to act as a role model. But pushing on down the tracks faster and harder, pushing those around you to do the same, pushing towards that one goal, has to be tempered with an element of self doubt, treated with openness of thoughts. It’s interesting to note that, in the staff survey referred to at the start of this post, more people were bullied by colleagues than managers. It could be you.

Think about this: ‘Am I creating the right conditions for people to speak up to me? Am I reacting to people in a way that tells them I want to hear what they have to say?’ Remember it’s what’s right – not who’s right – that counts. By all means be decisive – be a leader, push and challenge those around you – but make sure you listen and acknowledge people, and NEVER frighten or de-value those around you. You’ll have already lost the respect of those same people, and your situational awareness will never be complete again.

Imagine a quaint country GP’s surgery (surely a million miles from a cutting edge safety critical industry?) In the pharmacy, an inexperienced new starter queries the process of preparing some items for dispensing. The trainer can’t believe she’s been challenged. She responds sarcastically and, in doing so, delivers a powerful lesson: if you see anything unusual, shut up and do it my way.

That’s not an acceptable lesson on the flight deck, or in a nuclear plant, or during a Formula 1 pit stop. Why should it be accepted in healthcare where you’re all at the cutting edge of safety?

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group.