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Impact of Workplace Bullying in the NHS on Patient Outcomes

Paper Type: Free Essay Subject: Human Resources
Wordcount: 3461 words Published: 23rd Sep 2019

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Literature review

Aims and Objectives



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The NHS is one of the biggest employers in the world and supports its people with careers that spread over 60+ different specialities. The NHS celebrated 70 years last year and in the main is a people business, relying on compassion and goodwill. These people work across multiple locations and in multiple sectors. In essence the NHS is an extremely complex system and in recent years is being developed more as a system prior to this change organisations worked in silo’s. For the people working within and leading in this system and with the increasing complexity it has become more and more difficult. People are however enthusiastic about their jobs and the difference it makes to patients (staff survey, 2018) but over a quarter of staff have experienced harassment, bullying or abuse from other staff in the last 12 months ( staff survey, 2018). “Great quality care needs great leadership at all levels” ( Long term plan 2019) . In any organisation the culture reflects the values and beliefs of its leaders ( Barrett, 2010) although there are many vacancies at the most senior levels, a recent study from the Kings Fund (2018) found 8% vacancies at Executive Director level and 37% of Trusts had at least one Executive Director vacancy. Developing cultures of compassion and inclusion will be key and it has been shown that staff engagement can make a difference to patient outcomes ( Adamson, 2014,). However there are gaps in the research particularly linked to the impact in the workplace on bullying behaviours (Jenkins,2011) and the impact this may have on patients and patient outcomes. There is a gap in the current literature on the behaviours of leaders and alleged bullies and the impact of the processes that those leaders go through or put other people through.


There are many studies with particular reference to the NHS on leadership and an increasing number of studies in recent years about the importance of staff engagement and the impact in the NHS of staff engagement, on patient experience. These studies link staff engagement to improved mortality, reduced infection and reduced length of stay. (Macleod, 2009, Ham, Kings Fund)

There is an inherent belief that an ‘organisation reflects the values and belief systems of the leaders’ within the organisation. (Barrett, 1998). If those behaviours are of a bullying style what happens within the organization? Following this principle then, it could be said that engagement can be as much about leadership as it is about other factors. Much has been written about leadership and the styles of leadership. Most leadership theory is based around what and how leaders ‘do’ to their followers. The original theories of leadership were concerned with ‘transactional leadership, where the focus was very much on maintaining the ‘norm’. From the 1980’s the theories of leadership moved into transformation (Peters and Waterman; 1982), this led to theories around charismatic leadership and defining visions. (Bass; 1985,1998;Conger; 1989,House; 1977,Sashkin; 1988).

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This falls short of what is needed to engage however, but does begin the links around leadership behaviours creating the environment whereby employees would increase their effort to achieve outcomes. Interestingly Collins in “Good to Great (2001) challenged the notion of a charismatic leader and his research defined ‘humility’ as one of the attributes of the leaders that had taken companies from ‘good to superior’. Recent theory has now begun to focus more on authentic and engaging leadership (Northouse, 2010, Yukl, 2010, Holbeche,2006 Alimo-Metcalfe, 2008) and it is this type of leadership that focuses more on engaging with employees.

There are many definitions of engagement, this definition is good and keeps it simple;

‘ a positive attitude held by the employee towards the organisation and its values’ (Robinson 2004).

Most of the work around engagement appears to be focused on the discretionary effort that employees give freely when they are more engaged.

Hertzberg as far back as 1959 was communicating about the factors that motivated staff and the extra factors that he called hygiene factors. The fact is that employee’s want work to be meaningful, in fact research carried out at Roffey Park confirms that to be the case.

 Kotter and Heskett (1992) found links between companies that value employees and business success as did the survey from Roffey Park (management agenda). The Department of Trade and Industry (2002) survey had numerous links to employee involvement as a key ingredient of a modern high performance workplace. This report had various examples of high involvement work practices including:

  • Employee participation in decision making
  • Freedom of expression
  • Extensive team work
  • Employee involvement in the management of work.

There have been a number of studies that link the outcome of employee engagement on company performance (Towers Perrin; 2005, Watson Wyatt; 2006,2008); these outcomes are significant with profit being 28% higher than companies with low engagement.

In public sector then the impact of low engagement and its consequences on attendance and staff turnover can be one of the highest areas of cost. In the trust that is part of this study then absence alone cost £8 million last year.

Beverley Alimo Metcalfe carried out a study on ‘engaging leadership’and proved links between leaders behaviours and employee impact. This impact has also been mentioned in the Kings Fund report (No more heroes; 2011). It has been built on in 2012 with the report ‘together we can’. The government also had a review on the benefits on engagement on outcomes (MacLeod and Clarke; 2009). This report suggests that staff need’ autonomy, support, recognition and encouragement’.

Engagement in the NHS is linked through the staff survey and also the Constitution in being involved in decision making. The staff survey has been around since 2003 and questions relating to engagement since 2009. According to the Kings Fund study it measures these on three scales, motivation, advocacy and involvement.

West and Dawson (2012) compared engagement scores with patient outcomes and created the links between high levels of staff engagement and also mortality and infection.

Engagement needs to be authentic and cross organizational boundaries, when this happens staff are more engaged, even according to the Royal College of Surgeons, too many initiatives are focused on specific work groups. Cross functional working reduces stress and too much stress can harm care. In 2009 the Boorman report found that high levels of stress can cause poor organisational performance.

The majority of the literature supports the view that engaging staff creates an environment or a ‘climate’ where staff can achieve and give more of their discretionary effort. This effort would mean that patients in our care would have the potential for better outcomes.


To determine the impact of leadership behaviours on morale, bullying and patient outcomes.

  1. Review literature on staff engagement, leadership, bullying and the impact that these areas can have on patient outcomes and improved productivity.


This study will aim to show and validate the literature on employee engagement and the links from this to patient experience and outcomes. I have designed and lead the Trust Organisational Development Strategy, there are a number of strands to this strategy, of which part is the engagement work. An element of this work is done in partnership with Listening in Action (LIA), which is a comprehensive, outcome-orientated approach to engage all the right people behind quality outcomes.

It is acknowledged that having designed a large part of the programme there will be the potential for bias in this study and the intention is to gather enough information to validate the interpretations made.

Qualitative research is more suitable than quantitative research, because of the in depth analysis that is needed to probe attitudes, behaviours and leadership styles.

A key part of the engagement work is the ability for teams to have a direct impact on outcomes. To do this I will follow the progress and interview ten teams for their views and opinions, that are working as part of the Trusts engagement programme. These teams have applied for and been selected to work on a three month programme, to be selected they have put a proposal together to show the impact of an engaged process on their project. Their work will be launched on 5 February 2013. Each of the teams will have a mid-process review and a final review.

The research for this dissertation will be more suited to the phenomenological approach, rather than the positivist approach, which is based more on scientific research (Saunders, Cryer). It has to be said though that an element of the results may be more suited to the positivist approach. There will therefore be a mix of the approaches within the results.

My roles over the last twenty years, and the experience that I have gained allow for me to conduct in depth interviews without needing to learn new skills.

The methodology will include an initial questionnaire to investigate how the ten teams view their current environment and to give a base starting point. This same questionnaire will be used at the end of the three months to see if there is any change. This questionnaire will be asked of all ten teams and their sponsors. From this three teams will be chosen and a further in depth questionnaire, building on the responses from the first questionnaire will be given to these teams. This will be done twice over the three months, with the aim of seeing how the teams progress with development and engagement.

The outcomes of all ten teams will be reviewed and these will be assessed quantatively for success with patient outcomes.







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