An assault on dignity

An entrenched culture of bullying and harassment within the NHS workplace is taking a toll on the wellbeing of employees and is having a serious impact on the effectiveness of healthcare services. The clamour for more concerted action to tackle unacceptable behaviour is growing

12 February, 2019 / indepth
 Tim power  

Bullying within the workplace can take many forms, including verbal, non-verbal, psychological or even physical abuse. It can involve rudeness and constant arguments as well as unacceptable criticism, and situations where people are overloaded with work, ignored or isolated from others. It not only has a detrimental effect on people’s wellbeing but on their work performance as well… and that’s when it becomes a major issue for both healthcare services and patient care.

In recent years the focus of bullying has moved beyond the schoolyard and internet into the workplace, with particular emphasis on people working in healthcare settings. Although there are, as yet, no studies of bullying in the dental sector specifically, the issue is highlighted in a number of NHS-related studies and surveys, which include feedback from NHS dentists.

Extensive research by academics has shown the adverse impact of bullying and harassment on the wellbeing of employees in care settings and on the quality and safety of care they provide. Staff affected by bullying can experience a range of different emotions such as upset, anger and isolation which can lower their motivation, confidence, self-esteem and resilience and develop into more serious mental health conditions such as anxiety, stress and depression.

In some cases, subjects of bullying have shown symptoms of post-traumatic stress disorder. In addition to causing a range of serious health impacts, research has shown that people subjected to bullying are less likely to work in effective teams, raise concerns or admit mistakes – and this has potentially serious consequences for patients.

This situation has alerted the UK Government to the dangers of bullying, both for staff wellbeing and patient treatment. Health Minister Stephen Barclay announced recently that he wanted the “fit and proper” person test for NHS directors, which was introduced in 2014, to be widened to require action on harassment and discrimination. This was on the back of the care scandal at the Mid Staffordshire Hospital Trust and the results of the latest NHS staff survey which show that one in four employees had experienced bullying, harassment or abuse.

Examples of bullying behaviour


  • Sadistic or aggressive behaviour over a period of time
  • Excluding people from meetings for no good reason
  • Humiliating or ridiculing others or criticising others in public
  • Persistent, unwarranted criticism of others in private
  • Treating colleagues as if they were incompetent
  • Changing work responsibilities or academic assignments unreasonably or without justification
  • Regularly changing work deadlines or work guidelines without warning
  • Deliberately withholding information to affect a colleague’s performance
  • Withholding support in the academic environment or workplace
  • Cyber bullying conducted via social networking channels.

This list is not exhaustive: remember, bullying is any behaviour that is unacceptable to you or makes you distressed.

Long-standing culture

In Scotland, NHS Highland is under investigation for an alleged “long-standing bullying culture” after four doctors raised their concerns with a newspaper that the working environment was damaging patient care.

Examples such as this, along with NHS staff surveys that also capture feedback from dental professionals, led British Medical Association (BMA) Scotland council chair Lewis Morrison to warn about the repercussions for patient care in his recent Christmas and New Year message if the “scandal” of a culture of bullying and harassment was allowed to thrive in the NHS.

He said the BMA would launch a major initiative in 2019 to understand doctors’ experience of this unacceptable behaviour, to probe causes, and find solutions. He was also calling on other stakeholders, including the Scottish Government and NHS managers, “to work together to make Scotland’s NHS a more positive place to work”, and was planning a summit for early summer. A recent BMA survey of its members (BMA Scotland 2018 Membership Survey) revealed that almost four in 10 (38 per cent) say that bullying and harassment is an issue in their workplace.

Dr Morrison said: “Doctors have told us that bullying and harassment is still widespread and recent high-profile cases only serve to underline those concerns. Ultimately, the levels of bullying and harassment we currently see in Scotland’s NHS can only have serious negative repercussions for the care it provides.”

This concern is mirrored south of the border too from the results of the 2017 NHS England staff survey that shows no substantial movement from the previous year in the measures of bullying, harassment and abuse against staff, whether by patients and relatives (28 per cent) or by managers and other staff (24 per cent).

Of the 30,000 doctors and dentists who responded to the NHS England staff survey in 2016, 24 per cent reported that they experienced some form of bullying or harassment in the preceding year: 13 per cent of doctors and dentists said they had been bullied or harassed by their manager, while 16 per cent said they had been bullied or harassed by another colleague.

According to this survey, only a minority of doctors and dentists who experienced bullying or harassment reported it to their employers. The report suggests that bullying will often go unchallenged, particularly among trainees. For example, only 27 per cent of trainees who experienced bullying and harassment said they or a colleague had reported it, compared with 33 per cent of consultants and 36 per cent of other specialty and associate specialist grade staff.

Constant bullying and harassment not only takes a toll on the wellbeing of employees but on the effectiveness of healthcare services. A recent study on the impact of bullying in the NHS in England put the cost at £2.281 billion based on sickness absence, sickness absence costs to the employer, employee turnover, diminished productivity, sickness presenteeism, compensation, litigation and employment relations costs. The biggest financial impact is from sickness presenteeism due to bullying, costing £604.4m a year – this is the productivity lost when staff come to work while being bullied.

Despite the serious impact on healthcare services there is no law specifically against bullying. However, under the Health and Safety at Work Act 1974 employers do have a duty to ensure the health, safety and welfare of their employees, which can be compromised by bullying and harassment.

Bullying may be characterised as offensive, intimidating, malicious or insulting behaviour, an abuse or misuse of power through means intended to undermine, humiliate, denigrate or injure the recipient. Harassment, however, is defined in the Equality Act 2010 and relates to unwanted conduct affecting the dignity of men and women in the workplace. It may be related to age, sex, race, disability, religion, sexual orientation, nationality or any personal characteristic of the individual, and may be persistent or an isolated incident. The key is that the actions or comments are viewed as demeaning and unacceptable to the recipient.

In the workplace, bullying and harassment can come from managers to their subordinates or from individual colleagues or groups of people, but patients can also present bullying behaviours, particularly if their expectations have not been managed and they threaten legal action.

As the NHS surveys illustrate, very few people subjected to bullying and harassment formally report it. In its recent report on workplace bullying and harassment of doctors, the BMA highlights factors identified as likely to lead to a bullying culture, such as autocratic, target-driven management styles, poor job design, work intensification, and pressures arising from restructuring or organisational change, especially when radical and top-down. Another factor they raise that can lead to a bullying culture is the hierarchal nature of the medical profession which, along with workload pressure, can increase the likelihood of ‘silent bystanding’ – a failure of colleagues to speak out – which allows bullying behaviour to continue unchallenged.

In its report, the BDA is calling for more comprehensive organisational approaches that focus on ensuring work wellbeing and good workplace relations so that behaviours like bullying do not arise.

Unsurprisingly, there are a number of high-profile campaigns and initiatives designed to tackle bullying cultures within healthcare that have been launched as the scale of the problem has become evident. One of these is the Royal College of Surgeons of Edinburgh (RCSEd) #LetsRemoveIt campaign which has brought together groups across different healthcare specialties.

It was launched after the college’s own membership survey showed that nearly 40 per cent of respondents reported that they had been victims of such behaviour, with the same amount reporting that they had witnessed it.

The RCSEd has collated a suite of resources on its website to help people to understand and identify bullying and harassment and speak up and report it. It also includes a number of reflective resources for managers to consider for their own actions (see panel below) and also advice on how to be assertive without being a bully: by keeping goals level-specific rather than personal.

It must be recognised that some people, particularly managers, may not realise or perceive that they are behaving like bullies and that their conduct is seen by others as unacceptable. They are often highly competitive and successful people who thrive in a different work value system and may not be conscious of the sensitivities of the people they work with. The stresses at work can also cause people to behave differently, and that behaviour becomes reinforced until it becomes ‘acceptable’ and part of the culture in the healthcare setting. That is why it is important for people to respectfully challenge these behaviours and make it clear to the ‘bully’ that their behaviour is unacceptable.

On its website, the NHS advises people who believe they are being bullied at work to first seek informal advice from a trusted colleague in order to discuss how they might deal with the problem – by sharing experiences with others they may discover that it is happening to other people too.

Other people to consider raising the issue of bullying with include a manager or supervisor (if that is suitable), someone in the organisation’s human resources department or an employee representative, such as a trade union official. If the bullying is affecting someone’s health, then they need to visit their GP.

“Doctors have told us that bullying and harassment is still widespread and recent high-profile cases only serve to underline those concerns”

Dr lewis Morrison

NHS advice on dealing with a bullying situation:

Be strong

Recognise that criticism or personal remarks are not connected to your abilities. They reflect the bully’s own weaknesses, and are meant to intimidate and control you. Stay calm, and don’t be tempted to explain your behaviour. Ask them to explain theirs.

Talk to the bully

The bullying may not be deliberate. If you can, talk to the person in question, as they may not realise how their behaviour has affected you. Work out what to say beforehand. Describe what’s been happening and why you object to it. Stay calm and be polite. If you don’t want to talk to them yourself, ask someone else to do it for you.

Keep a diary

This is known as a contemporaneous record. It will be very useful if you decide to take action at a later stage. Try to talk calmly to the person who’s bullying you and tell them that you find their behaviour unacceptable. Often, bullies retreat from people who stand up to them. If necessary, have an ally with you when you do this.

Make a formal complaint

Making a formal complaint is the next step if you can’t solve the problem informally. To do this, you must follow your employer’s grievance procedure.

What about legal action?

Sometimes the problem continues even after you’ve followed your employer’s grievance procedure. If nothing is done to put things right, you can consider legal action, which may mean going to an employment tribunal. Get professional advice before taking this step.

Other resources on bullying:

Here is a checklist to help you think about how your behaviour might impact on others (source:

  • Do you listen to the other members of your team or do you do all the talking?
  • Do members of your team come to you with ideas or suggestions?
  • Does your sense of humour involve jokes that could be racist, homophobic or sexist?
  • Do you feel that ‘you had it tough so they should too?’
  • If you are senior, do you use your position to offer mentorship or do people go to others for this?
  • Do you always apologise to someone if you lose your temper?
  • Have you written derogatory comments about someone on WhatsApp, Facebook or Twitter?
  • Do your colleagues look you in the eye?
  • Do you ignore any of your colleagues?
  • Do you blame others for problems that occur?
  • Do people speak freely in your theatre / clinic or do you dictate how people behave?
  • Does banter form a big part of your interactions with others?
  • Have you ever fired off an angry email?
  • Do you prefer to email colleagues about difficult situations, rather than discuss things face-to-face?

Tags: 2019 / assault / bullying

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