Bullying, harassment, and incivility involving NHS staff could be costing the health service around £2.3 billion a year, according to a study published in the journal BMC Medicine.
Researchers from the University of Surrey said unprofessional behaviour was "pervasive" in acute healthcare settings, to the detriment of staff wellbeing, organisational resources, and patient safety, while also disproportionately harming minority groups.
The study evaluated measures that could be taken to mitigate the problem.
The researchers cited recent examples in the NHS that demonstrated the prevalence of unprofessional behaviour, such as a 2023 investigation into clinical safety at University Hospitals Birmingham NHS Foundation Trust that revealed a pervasive culture of "bullying and toxicity". Similarly, the East of England Ambulance Service Trust faced monitoring by the Equality and Human Rights Commission because of sexual harassment and abuse.
Serious Misconduct Cases in the NHS
The authors noted that between 2017 and 2022, more than 4000 NHS staff had been accused of severe misconduct, including sexual assault, harassment, stalking, or insults directed towards colleagues or patients, yet only 576 faced disciplinary action.
Unprofessional behaviour has been described as an unaddressed crisis in healthcare, they said, yet interventions to address such behaviour "are still at an early stage of development", and their effectiveness is unclear.
The researchers conducted a literature review encompassing almost 3000 global sources, which included 148 full text reports with 42 reports describing interventions to address unprofessional behaviours among staff in acute healthcare settings.
They found no reports of solutions evaluated in the UK.
Key Dynamics in Interventions
Following the review, the team formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work.
They identified 12 key dynamics to consider in designing interventions and avoiding common pitfalls that can lead to unintended consequences, with 15 implementation principles to address these dynamics. These include:
- Assessing the role of workplace culture and systemic contributors
- Promoting a psychologically safe culture that encourages employees to speak up and makes it easy to do so
- Developing an accurate way to measure success – increased reports of bad behaviour is not necessarily a negative outcome if it means increased awareness
- Ensuring interventions have support from the top down, and rebuilding trust in managers as necessary
- Ensuring no one is left out – minorities and women face more bad behaviour but are often overlooked in solutions
- Ensuring strategies are adaptable, flexible, and able to evolve for different situations – though this can make it harder to figure out what actually works
- Reviewing anonymous reports – allowing anonymous complaints can be misused, and a review system can help to prevent this
Almost Half of Healthcare Staff Have Experienced Unprofessional Behaviour
Principal investigator Jill Maben, professor of health services research and nursing at the University of Surrey, said, "Bullying alone costs the NHS upwards of £2 billion a year, with nearly half of staff saying they have experienced some form of unprofessional behaviour from colleagues, leading to many considering leaving the service. It is crucial that we take action soon and prioritise the implementation of interventions to rid the NHS of this scourge."
"We also need to better understand the root causes and the context in which these behaviours occur, especially as they disproportionately affect women and minority staff."
Co-author Dr Ruth Abrams PhD, a lecturer at the University of Surrey, said, "This study isn't just a theoretical, academic exercise – this is about ensuring the wellbeing of healthcare workers and, ultimately, the patients they serve. It's high time the UK NHS takes this as seriously as health systems in the USA, Canada, and Australia."
The authors highlighted that current approaches largely overlook the challenges faced by women, staff from minority backgrounds, and those with disabilities. Yet they found only one existing intervention specifically aiming to tackle racism in acute care settings.
The research was funded by the National Institute for Health and Care Research, which also this week announced funding for a project co-led by Glasgow and Aston universities to help the NHS tackle discrimination and bullying in the workplace.
Project co-leader Rosalind Searle, professor in human resource management and organisational psychology at the University of Glasgow, said, "Our health workforce draws on the talents from across the world to provide outstanding care. Yet this is a workforce that experiences high levels of bullying, harassment, and discrimination."
The new project will aim to understand how NHS workplaces currently deal with the challenges and identify how this could be improved to forge a more inclusive working environment. This information will be used to develop a 'smart' NHS information tool for automating data collection and analysis, and identifying the most effective changes to make and how to make them.