A review into culture and bullying at University Hospitals of North Midlands NHS Trust

Most immediately, we would suggest the Trust needs a big, long-term plan to ‘re-humanise’ the organisation. The Trust’s existing culture has permitted, and continues to permit infringements in behaviour. While this is not condoned by senior leaders in the trust, the lack of a plan to proactively tackle a legacy of overlooking poor behaviours has allowed them to persist. This needs to be acknowledged, and the desire to create a more inclusive and equitable culture placed firmly on the table and reiterated frequently (so that it is believed). As part of this plan, trust leadership will need to articulate a clear vision of the types of behaviours it expects to see, the activities it will undertake to promote these, and a rationale as to why this is important. The vision should explain how promoting more collegiate behaviours can help promote the trust’s mission, values, and strategic objectives. In doing so it will make explicit the link between promoting more professional behaviour, staff experience, and the positive impact this will have on the issues staff care about the most – patient care and safety.

The Trust’s existing culture surveys provide a range of useful measures of workplace experience. The Trust should work with staff to identify other measures of civility and compassion it can collect. Data relating to these measures should be presented to the Board, disaggregated by band, directorate, and ethnicity (as a minimum). Responsibility for improving reporting against these measures should lie with the Chief Executive.

The importance of early, informal intervention to resolve workplace issues has been widely noted. As stated above, it is not entirely clear why HR colleagues formalise issues in the first instance. However, in other trusts, this often stems from a fear of pushback or challenge by the alleged perpetrator (particularly when the alleged perpetrator is a doctor). Being able to say policies are being followed and referring to the ‘evidence’ provided by the complainant are natural defence mechanisms. If this is the case, having a strong narrative around tackling unprofessional behaviour will help staff when dealing with pushback. In ‘lowering the waterline’ HRBPs and managers will require backing from the Trust if they are to address unprofessional and inappropriate behaviour informally. As we have noted, though, there is appetite amongst HRBPs to work this way, and this enthusiasm needs to be leveraged. HR colleagues may need support to work more informally. They will need to be able to recognise covert discriminatory behaviours and address deftly concerns people have about the intent behind their colleagues’ behaviours and not just their impact. This type of work involves being able to hold ‘braver’ conversations to adequately interrupt poor behaviours before they escalate. Any new development process should enable HR colleagues to recognise micro-aggressions and micro-inequities and be more competent in talking about these and the impact of them in relationships between staff. An informal process to lessen micro-aggressions could be a specific target adopted by the Trust.

Many of the interventions the Trust has employed are not directed at those who need them the most. Furthermore, at a fundamental level, there is a lack of awareness of how power is used or not used and the impact that this has on the organisation. We would highly recommend the Trust explore the use of the Diamond Power Index (DPI). The DPI is an individually employed 360o tool that is specifically designed to assess how leaders use their power. It works on how people ‘experience’ leadership: whether leaders are fair, empowering, and approachable, for example. These dimensions are central to some of the existing leadership dilemmas within the Trust. Feedback to leaders on how they are experienced can be used in one-to-one coaching. Furthermore, and in relation to those areas of the Trust where there are greater concerns, a team profile can be produced, using the individual feedback scores (see point (iii) on divisional/department specific work). The team profile is still confidential, but presents a holistic view of how leaders in the area are experienced and what the leadership team needs to do to take action. The Trust may find it useful to create a managers peer support network to support managers to learn from best practice from those more experienced or working in some of the better-performing teams. This can function in both formal and informal ways. All newly appointed clinical leads and directors without adequate managerial experience should receive a mentor for the first 12 months of their tenure. To ensure the relationship is beneficial, this should be built into both the mentor’s and mentee’s appraisal procedures. Training packages should recognise head on barriers to implementation: in particular, how racism and respecting professional hierarchies can hinder the implementation of some of the course content. Given the distress poor behaviours create, the Trust should review the resources they offer to support staff and how these are deployed.

There are some areas within the Trust – Anaesthetics, Critical Care and Theatres; Obstetrics and Gynaecology; Trauma – which would benefit from intack team leadership development. By this we mean that leaders of these teams should be given the opportunity to both individually and collectively appraise their leadership styles and approach. (The Diamond Power Index can also be used for this purpose.) There may also be opportunities for some of these departments to learn from other parts of the trust where bullying and harassment is less pervasive (see page 12). The proportion of staff experiencing race-based harassment or abuse from patients/visitors is higher than we would expect and clearly unacceptable. The BMA has just this month issued useful guidance on this topic that addresses some practicalities involved in responding to patient discrimination. We would recommend the Trust review this guide.

Multidisciplinary meetings should be reviewed to ensure they take an educational, supportive approach. All teams could adopt a similar process and this could be embedded by a number of ‘meeting gurus’ whose role is to support teams to adopt similar standards.

There is a need to work intensively with particular individuals who have grievances going back a number of years. We have suggested the Trust’s past approaches have failed to tackle the root causes of their concerns. The approach adopted by the new Medical Director and clinical leads is to be welcomed. However, to surface these individuals’ underlying issues and deal with them in an emotionally competent way will require time and expertise. It may be beneficial to provide particular individuals with an (external) coach who can support them with their development.