Scarlett McNally: We must all change, not just the bad apples

A recent report by the Working Party on Sexual Misconduct in Surgery found that 30% of women surgeons surveyed had been sexually assaulted by co-workers.12 In response to the report there have rightly been demands for improved reporting structures and better support after an assault. But we also need prevention. Toxic workplace cultures allow poor behaviours, including sexual misconduct, to flourish. Most of us haven’t been explicitly taught how to behave or communicate since school. But we all need to change, and so do some cultures in the NHS.

Two recent academic studies show that a focus on “bad apples” isn’t sufficient to tackle bad behaviour in the workplace. A study by the University of Surrey3 showed that whole team interventions for behaviour change, such as full team meetings or workshop sessions to improve clarity and communication, can be successful and that managers need to improve their competencies—especially around being clear, fair, receptive, and respectful. Systemic issues such as understaffing, stress from the way work is structured, and lack of resources should be improved, as they contribute to poor behaviour. People need the psychological safety to speak out about concerns without fear or repercussions.

Another study, by the Royal Australasian College of Medical Administrators,4 has shown which interventions are successful, such as training about communication across hierarchies and about feedback mechanisms—which, with good leadership, can help to maintain psychosocial health and avoid stress reactions. Fair and visible responses are also needed when poor behaviours occur.

“Zero tolerance” of issues such as bullying and misconduct is unhelpful, as it “reinforces an absolute or binary idea of good and bad practices, shaping reporting behaviours to disclosure only when issues have passed a discrete threshold.”4 Through my involvement in investigations for my healthcare trust, I found that the NHS investigation process can be painful, slow, and secretive. When the Royal Australasian College of Surgeons started its work on “respect” it found that most people who were accused of bullying were unaware of how they were perceived, and widespread education for behaviour change was effective.5 This underlies the need for each of us in the NHS to behave respectfully to improve its workplace culture.

Unprofessional behaviours are common and harm patient care. The Royal College of Surgeons of England has undertaken invited visits of more than 100 surgical departments in NHS trusts that have had difficulties in recent years, reporting that 76% showed problems with teamwork and that 54% showed poor individual behaviours.6 When staff behaviours are bad, patient care worsens.7 Women and marginalised groups experience more of these unprofessional behaviours.3 Bullying and harassment are estimated to cost the NHS over £2bn a year just in litigation, sickness, and staff turnover.8 Hence, reducing poor behaviours in the NHS would be cost effective, as well as better for staff wellbeing.

Co-workers need some codes of conduct about what is and isn’t appropriate to say in the workplace.1 The National Safety Standards for Invasive Procedures show how to do a team brief, being clear about each task and role.9 Managers and leaders at all levels should highlight a minimum standard of required behaviour. Many other countries’ health services are further ahead with improving their culture by encouraging individual behaviour change, and they can provide examples for the NHS to follow.3

Let’s improve the culture in the NHS together, by realising that we might be part of the problem and by trying harder to value everybody and behave professionally.