Over a working lifetime, most people probably spend more time at work than they do with their families at home. In the employment context, we talk about relationships and the need to maintain them. Some view their colleagues at work as a family, where a breakdown of relationships can take a huge emotional and physical toll on the employee.
The development and continuation of good working relationships is essential for the success of any enterprise. A poorly motivated dysfunctional workforce where the staff don't relate well to each other and to their clients means that the enterprise is pretty much doomed to failure. Worryingly we can see some of this behaviour manifested in the NHS when patient safety inquiry reports are analysed.
Kirkup (2015: 7) in the Morecambe Bay inquiry report stated that the root of the problems described lay in ‘the seriously dysfunctional nature of the maternity service at Furness General Hospital’. This led to what was termed a ‘lethal mix’ of issues, which the report said undoubtedly led to the unnecessary deaths of mothers and babies:
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives …’
Seven years later, the report of the East Kent inquiry repeated similar concerns:
‘We found clear instances where poor teamwork hindered the ability to recognise developing problems, and escalation and intervention were delayed. The dysfunctional working, we have found between and within professional groups has been fundamental to the suboptimal care provided in both hospitals.’
The poor teamwork and relationships identified in these two reports can be seen to be repeated in several others. Sadly, these are not isolated problems in the NHS. Problems with staff bullying, poor working relationships, harassment or incivility are well documented. They appear to be pervasive, underpinning problems hindering the development of an effective NHS patient safety culture.
The Nursing and Midwifery Council (NMC) in its 2022 leavers' survey gave workplace culture as the fourth most frequently cited reason why nurses leave the NMC register, and calculated this at 13% (NMC, 2022: 10):
‘A number of respondents (113; 4.8 percent) described the environment as toxic, and directly noted that bullying in the workplace was a reason for their leaving.’
The development of a just, compassionate, and caring work culture is essential to patient safety and the wellbeing of individual nursing and other staff. Failures can result in complaints and litigation.
NHS Resolution: Being Fair 2
NHS Resolution (2023) has produced advice on promoting a person-centered workplace that is compassionate, safe, and fair. Being Fair 2 builds on the earlier Being Fair (NHS Resolution, 2019). The fact that this second report was needed at all shows the depth of the workforce problems in the NHS and their pervasive nature. Much more needs to be done on the issues of poor working relationships, staff bullying, harassment, incivility and how concerns about staff are managed.
There is a discussion of the scale of the NHS workforce problems and the impact this has beyond the human cost. There is an economic cost, which includes litigation claims, employee turnover and so on. There is a section dealing with insights from stress-related claims where the relevant statutory provisions concerning health and safety in the workplace are discussed. Several reports relevant to health and safety in the health sector are also discussed.
Themes from past stress-related litigation cases are analysed along with the financial costs of claims. There is a section on improving working culture and how to do this. Other sections of the report deal with fair recruitment, induction and supervision processes, fair resolution of concerns, features of success, and a revised Just and Learning Culture Charter.
The report makes frequent reference to other reports and resources and as such provides a useful toolkit resource, with the express purpose of the report being:
‘… to encourage and support organisations to take an evidence-based, proactive approach to ensuring that the behaviours underpinning a just and learning culture are embedded and that there are processes in place to support fair resolution should an incident occur, or concerns emerge.’
Stress-related litigation claims
Resorting to litigation to resolve disputes should be seen as the last resort when everything else has failed. If litigation can be avoided, then it is to everyone's benefit. It is expensive, time consuming and stressful for all concerned. It is stated in the report that there were 135 stress-related claims with a total cost of £14.2 million (closed settled claims with damages paid including legal costs) between fiscal years 2010 and 2020. The amount of damages paid out was £7.5 million (NHS Resolution, 2023: 10)
In terms of the recurring themes these are described as lack of support, difficult working relationships, and poor behaviours.
‘Poor “relationships” at work were identified as a contributor of work-related stress in 81 (60%) of the overall claims, and 81% of these involved bullying and harassment. Claims concerning bullying and harassment accounted for 53% of the overall stress claims (71 claims closed with damages paid). The total cost of these claims was £6.3 million with £2.7 million being paid out in damages alone.’
Although these figures do not reach the high levels of some clinical negligence compensation claims that are widely reported in the media they are nevertheless significant. They show that avoidable failures in workforce relations have taken place, which have resulted in considerable stress. The money paid out in damages could have been used elsewhere.
Updated Just and Learning Culture Charter
The first Being Fair (NHS Resolution, 2019) included a suggested ‘Just and Learning Culture Charter’ for organisations to adapt. The Charter contained key expectations, and pledges of how the organisation will act to promote a just and learning culture – what patients and others should expect to happen and when.
The new report presents an updated version, which includes section heading titles and has roughly double the content of the previous version. Headings in the revised Charter with supporting narrative are: Accountable, Leadership, Wellbeing, Compassion, Inclusive, Respectful, Candour, Learning, Best practice, and Evaluation.
Overall this second report is comprehensive, clear and leaves the reader in no doubt as to what is required to develop ‘a person centered workplace that is compassionate safe and fair’ (NHS Resolution, 2023: 4).
However, behaviours and cultures don't change overnight, they develop, largely incrementally, over a period of time. This can be viewed as an important wake-up call and step forward, for the NHS to better improve on its efforts to develop a sustainable just and learning culture – efforts that do need to accelerate.
Improving patient safety culture: a practical toolkit
Keeping with the theme of NHS patient safety culture development, NHS England (2023) in partnership with the The ASHN Network (the national coordinator for local Academic Health Science Networks) has produced a draft toolkit for improving patient safety culture, which can currently be accessed through the Patient Safety Learning online hub. It is important to read this draft alongside the report from NHS Resolution (2023) as there are common themes.
Sections include safety culture, teamwork, and communication, just and restorative culture, psychological safety, promoting diversity inclusive behaviours, civility. Again, this toolkit makes reference to other helpful resources. The draft shows well-crafted sections, clear and easy to follow, with definitions of key terms:
‘A just culture is about creating a culture of fairness, transparency, and learning. It recognises that success or mistakes are the product of many factors and focuses on changing systems and processes to make it easier for people to do their job safely. It is about ensuring everyone is confident they will be treated fairly when something goes wrong.’
These two culture development toolkits will hopefully be discussed more across the NHS, and the messages incorporated into policies and practices. There is no doubt that there is the information out there to develop a fair and just NHS patient safety culture.
The challenge will be permeating the messages through into the workplace and time and scarce financial resources are needed to do this. It will be possible for trusts to pick and mix from the reports discussed and from others to determine the best solutions for them.
What do we mean by justice?
In determining the best solutions for trusts discussion, debate and analysis will be essential. Cribb et al (2022) discussed conceptions of justice and the need to unpack these:
‘The core question for all those interested in designing and implementing more “just” safety policies and procedures is working out which conceptions of justice they should work with and emphasise. We cannot just “pick” one conception of justice and neglect the others because they each make a relevant claim on us.’
Yet there is also the danger of information overload and of trying to do too much. Staff can be desensitised to the messages if they see them repeated too often. There has to be some selectivity of topics when unpacking the toolkits discussed. We can add to the mix of relevant publications the NHS Patient Safety Syllabus and the education and training curriculum guidance under this (elearning for healthcare, 2023).
Conclusion
There are endemic, pervasive culture problems in the NHS, which involve staff bullying, poor working relationships, harassment, incivility. These are well chronicled in several patient safety inquiry reports. The NHS has in the materials discussed here some effective tools to educate and train staff in good policies and practices in this area. There are also other reports and publications on the issue. The difficulty lies in devoting the necessary time and resources to getting the messages across to NHS staff in a meaningful way, avoiding message overlap and duplication, while allowing for debate and meaningful discussion of aims and purposes.