Bullying and Harassment in the Health Sector

Tabled: 23 March 2016

2 Workplace culture

At a glance

Background

A strong workplace culture consistently places a high priority on worker safety, including leadership commitment and clear accountability.

Conclusion

Leadership teams at health sector agencies do not place sufficient priority on reducing inappropriate behaviour including bullying and harassment. Poor accountability at multiple levels across the audited agencies and leadership's poor understanding of the hazard—particularly the causes, prevalence and impact of bullying and harassment—affect workplace culture.

Findings

  • The health sector has largely failed to identify bullying and harassment as a risk or to manage it through a risk management framework.
  • Reporting on the prevalence, causes and impact of bullying and harassment within audited health services was either absent or unreliable.
  • There is widespread fear among staff and a reluctance to raise issues or make formal complaints because of the perceived repercussions of doing so.

Recommendations

That health sector agencies:

  • apply a risk management approach to the prevention of and response to inappropriate behaviour, bullying and harassment, including identifying and reporting to the board the causes, prevalence and impact
  • detail clear responsibility and accountability for identifying and responding to bullying and harassment within policies and procedures
  • ensure that their boards use indicators to benchmark positive culture and monitor the risk of inappropriate behaviour
  • demonstrate to the Department of Health & Human Services that staff feel safer to report inappropriate behaviour including bullying and harassment and believe action has been taken in response to this behaviour.

2.1 Introduction

It is widely acknowledged that positive and respectful workplace culture and values are key to preventing and managing inappropriate behaviours, including bullying and harassment. A strong safety culture consistently places a high priority on worker safety. Leadership commitment and clear accountability are also needed to reduce the risk of bullying and harassment. Identifying the risk—by understanding the causes, prevalence and impact of bullying and harassment—and reporting to the leadership team is important so that they can respond effectively and assess whether controls are minimising the risk and, therefore, whether they are fulfilling their responsibilities as employers under occupational health and safety (OHS) legislation.

2.2 Conclusion

The leadership of audited health sector agencies do not place sufficient priority on reducing inappropriate behaviour including bullying and harassment. Poor accountability at multiple levels and leadership teams' poor understanding of the hazard—particularly the causes, prevalence and impact of bullying and harassment—undermine the workplace culture. Indicators include:

  • insufficient priority and leadership commitment to reducing inappropriate behaviour including bullying and harassment
  • failure to manage bullying and harassment through a risk management framework, despite it being a risk with serious consequences
  • poor accountability for inappropriate behaviour, bullying and harassment, including at senior levels within health sector organisations
  • pervasive fear and reluctance by staff to raise issues or make formal complaints because of the perceived repercussions of doing so.

There are some signs that audited agencies are attempting to change the culture within their organisations, to adopt one that does not accept workplace bullying and harassment. This is a long-term challenge which will require more sustained leadership focus and commitment than has currently been demonstrated.

2.3 Inadequate leadership commitment

The leadership—the board and executive of audited agencies—currently has inadequate governance and oversight of the risk posed by bullying and harassment. Although the leadership has a duty of care to its employees under OHS legislation, bullying and harassment is not given the level of priority the seriousness of the risk demands.

In addition, a failure to demonstrate consistent accountability for inappropriate behaviour, bullying and harassment, including at senior levels, was reported within all audited agencies, including a consistent failure to hold senior staff to account for inappropriate behaviours.

2.3.1 Insufficient priority

Health sector agencies have largely failed to identify bullying and harassment as a risk or to manage it effectively. While each audited agency describes bullying as a 'risk to health and safety', no audited agency applies standard risk management principles to its management of bullying and harassment.

This is despite the fact that the definition of bullying and harassment—nationally and by all state jurisdictions—emphasises the need to manage it through a risk management framework.

Using a risk management framework would allow agencies to identify and assess the potential for workplace bullying, to implement control measures to prevent, minimise and respond to these risks, and to monitor and review the effectiveness of these control measures.

The failure to recognise and address bullying and harassment through a risk management framework means that such behaviour is managed at the level of the individual on a case-by-case basis, with little focus on prevention and continuous improvement at an organisational level. This is all the more important given that changing culture is a long-term challenge.

By analysing the extensive data it collects on the public sector, the Victorian Public Sector Commission (VPSC) found that 'when behaviour is individualised, it has the potential to hide the underlying organisational factors driving the behaviour'. The 2012 Australian Parliamentary inquiry into workplace bullying found that only responding to bullying and harassment at the level of the individual can also lead to under-reporting and mask the extent of bullying and harassment, as:

  • bystanders are less likely to intervene or raise concerns about situations that are framed as individual, inter-personal conflicts
  • staff are less likely to have the confidence to report issues.

2.3.2 Failure to identify and understand the hazard

Because the reporting of bullying and harassment to leadership at the audited agencies is absent, inadequate, unreliable or inconsistent, it is difficult for leadership teams to discharge their duty of care to employees and manage bullying and harassment as an organisational risk—even when it is considered a priority. Failing to collect good data means that the leadership teams cannot respond effectively or assess whether controls are minimising the risk of bullying and harassment. Information reported to the boards of the audited agencies did not identify or quantify the causes, prevalence and impact of bullying and harassment. Instead, the information was very poor:

  • Three audited agencies do not report bullying and harassment complaints at all to their leadership teams.
  • The remaining two audited agencies report complaints to leadership, but these are aggregated with other human resources issues so it is not possible to understand the prevalence of bullying and harassment. For instance, one agency's report was limited to the total number of Fair Work 'arbitrations', 'conciliations', 'investigations and reviews' and 'concerns and inquiries' for that month, any of which might or might not relate to bullying and harassment behaviour.
  • In addition, other key information that should inform an appropriate response is missing:
    • trends over time in bullying and harassment complaints
    • clinical and operational areas with increased numbers of complaints
    • outcomes of complaints.
  • Broader organisational indicators, such as staff turnover, unplanned leave and absenteeism, are not integrated. Understanding rates of these indicators and richer data on the complaints process can collectively provide a better understanding of the prevalence and impact of bullying and harassment across an organisation.

One audited agency has recently begun reporting to the executive the 'number and outcomes of substantiated bullying, harassment and intimidation complaints', which is an improvement. Three audited agencies have also prepared one-off discussion papers on bullying and harassment recently, which combine multiple types of data to identify trends. One agency prepared this discussion paper after recognising that bullying and harassment issues were negatively affecting its reputation and ability to attract and recruit high-calibre clinical staff. This is a good example of how leadership should monitor these factors and interpret what the information means for the agency.

Despite inadequate information, the leadership of the audited agencies have not requested better or more information, or deeper analysis that could improve their understanding of bullying and harassment across their organisations.

Representatives of three boards acknowledged that they:

  • are unclear on what information they should be asking for and uncertain how to monitor workplace culture, bullying and harassment given the information they receive
  • are unclear how to respond appropriately, given the challenges bullying and harassment pose
  • need better training and support to fulfil this function, including knowing the right questions to ask, indicators of concern and best-practice responses for different types of issues
  • need stronger leadership from the Department of Health & Human Services (DHHS), particularly in providing improved training and support.

They also reported a desire for DHHS to develop indicators related to workplace culture.

Board representatives at the other two audited agencies were not aware of the inadequacy of the information they received and, therefore, of their failure to adequately monitor the issue. This was despite acknowledging that they did not know the causes, prevalence and impacts of bullying and harassment within their respective organisations. This only emphasises the need to develop board capability to understand and interpret relevant data and information, so that they all fully understand the risks they are responsible for.

Limited attention to improving inadequate information

Audited agencies have given limited attention to improving poor and unreliable information and building a stronger understanding about the causes, prevalence, impact and trends of bullying and harassment across their organisations. However, this is changing—two agencies are improving their respective OHS reporting systems, and three agencies are currently undertaking additional targeted surveys to determine the extent of bullying and harassment. It will be important for this information to be analysed and presented to the board for consideration.

While new surveys can be valuable, the whole health sector (including the audited agencies) has been slow to use the information that is freely available through VPSC's People Matter survey. The survey provides the option to the health sector of including questions on the work unit and role level, of each respondent. However, as of 2015, only 25 per cent of the Victorian health sector included these questions which enable agencies to identify where workplace bullying is reportedly occurring.

2.3.3 Poor accountability

Executive and senior management

Line managers and staff across all audited agencies identified poor role modelling in the behaviour of the executive and senior managers. Ten of 17 focus groups identified this issue, including five of the six line manager groups and four of the seven staff groups. These focus groups also identified a consistent failure to hold senior staff to account for inappropriate behaviours and described a 'double standard' whereby some staff are 'untouchable' despite their consistently inappropriate behaviour being common knowledge. Both line managers and staff stated that it was important to establish consistent expectations across the organisation—however, this becomes impossible if senior management model poor behaviour.

The Parliamentary inquiry and research shows that leaders and managers play a pivotal role in creating the culture of the workplace through what they say and do. Leaders need to model appropriate behaviour and deal with inappropriate behaviour when they become aware of it.

This is in stark contrast to what is reported to be the situation in the audited agencies. The majority of the focus groups (14 of 17) reported that there is no point reporting instances of inappropriate behaviour, including bullying and harassment, as nothing will be done. These views were held equally strongly across roles—the issue was reported in all junior doctor and paramedic focus groups, in the majority of line manager groups, and in the majority of staff groups, across all audited agencies. Along with the fear of repercussions, this belief makes staff reluctant to report incidents of inappropriate behaviour early, or at all. This finding is supported by analysis of the 82 public submissions received during this audit:

  • 40 per cent of all submissions (32 responses) stated that those with poor behaviour were not held to account
  • 23 per cent of all submissions (19 responses) identified issues with poor adherence to policies and procedures.
Clinicians

Line managers, staff and junior doctors across all audited health services reported that health services fail to hold clinicians to account for poor behaviour. This view was expressed by 10 of the 17 focus groups, or almost 60 per cent, including all six of the line manager groups, four of the seven staff groups, and two of the four junior doctor groups.

Group interviews with the board, executive and senior clinicians at two audited agencies agreed with the assessment that poor behaviour by clinicians is common. One of the executives, in an interview with VAGO, commented: 'Doctors are immune. This cannot go onwe cannot have different rules for different people, no matter how important they are.'

Findings from the focus groups are supported by an extensive 2015 national survey by the Royal Australasian College of Surgeons (RACS). In this survey, almost half (1 516) of all surgeons who responded to the survey reported experiencing discrimination, bullying, sexual harassment or harassment, as shown in Figure 2A.

Figure 2A
Experience of bullying and harassment—2015 Royal Australasian College of Surgeons survey

Issue

Prevalence

n(a)

per cent

Experienced discrimination, bullying, sexual harassment or harassment

3 079

49.2

Experienced bullying

3 079

38.7

Experienced harassment

3 079

18.8

Person exhibiting the behaviour was a surgical consultant

1 098

84.5

Person exhibiting the behaviour was male

1 088

81.1

(a) n = sample size.
Source: Victorian Auditor-General's Office using data from the RACS survey, 2015.

In addition, over half of surgeons (57 per cent, or 569 surgeons) who sought to address the behaviour were not satisfied with how the issues they raised had been resolved. Figure 2B details the low proportion of surgeons and trainees who felt that their issues of discrimination, bullying and sexual harassment were dealt with effectively.

Figure 2B
Ineffective response to clinicians' poor behaviour— 2015 Royal Australasian College of Surgeons survey

Survey question

'Yes' responses —
all respondents

'Yes' responses —
trainee doctors

'Yes' responses —
women

n(a)

per cent

per cent

per cent

'There is a supportive and inclusive culture that deals effectively with discrimination, bullying, and sexual harassment'

2 789

45.7

31.9

33.5

'The Hospital Executive deal effectively with persons who are displaying discrimination, bullying or sexual harassment'

2 750

34.3

19.4

22

(a) n = sample size
Source: RACS survey, 2015.

In interviews, the executives at three of the audited health services acknowledged their limited effectiveness in tackling the poor behaviour of senior clinicians. They reported that there were considerable barriers faced in addressing inappropriate behaviour including bullying and harassment. Barriers include the high cost incurred in legal fees, the time it takes to address complaints, the lack of clarity about accountability and the poor information exchange across speciality colleges, health services and universities.

2.4 Under-reporting of bullying and harassment

Focus groups of staff at different levels and the public submissions received during this audit overwhelmingly indicate high under-reporting of inappropriate behaviour including bullying and harassment. Half the senior managers interviewed also acknowledged extensive under-reporting. Significant under-reporting means that even if the reliability of the available data improved, it would still not provide a complete picture of the extent of the problem, including the true causes and prevalence of bullying and harassment across an organisation.

Our focus groups and public submissions identify consistent reasons for under‑reporting, including:

  • belief that there is little point in reporting incidents, as inappropriate behaviour including bullying and harassment is not addressed
  • distrust of human resources teams, who manage complaints of bullying and harassment
  • fear of repercussions.

The RACS survey also found indications of under-reporting and reported reasons consistent with those above. The reasons for under-reporting, by data source, are shown in Figure 2C.

Figure 2C
Reasons for under-reporting of bullying and harassment

Reason

Reported in focus groups

Reported in public submissions

Reported in RACS survey

Unwillingness to report

16 of 17 focus groups:

  • 6 of 6 line manager groups
  • 6 of 7 staff groups
  • 4 of 4 junior doctor groups

38.2%
(31 submissions)

Bullying—45%
(489 responses)

Harassment—43%
(210 responses)

No point (issues are suppressed)

14 of 17 focus groups:

  • 5 of 6 line manager groups
  • 5 of 7 staff groups
  • 4 of 4 junior doctor groups

39%
(32 submissions)

Distrust of human resources departments as a tool of management or as ineffective

10 of 17 focus groups:

  • 5 of 6 line manager groups
  • 5 of 7 staff groups

29.6%
(24 submissions)

Fear of repercussions

15 of 17 focus groups:

  • 5 of 6 line manager groups
  • 6 of 7 staff groups
  • 4 of 4 junior doctor groups

30%
(31 submissions)

All respondents—44.9%
Trainees—80%
Women—70.7%
31–35 year olds—93.4%

  • Damage to reputation

4 of 17 focus groups:

  • 4 of 4 junior doctor groups

36.5%
(379 responses)

  • Unfavourable rostering and leave

9 of 17 focus groups:

  • 2 of 6 line manager groups
  • 4 of 7 staff groups
  • 3 of 4 junior doctor groups

25%
(21 submissions)

  • Career progression, transfer, non‑renewal of contract

8 of 17 focus groups:

  • 4 of 6 line manager groups
  • 4 of 4 junior doctor groups

17%
(14 submissions)

50%
(613 responses)

Source: Victorian Auditor-General's Office.

While there was a consistent unwillingness to report behaviours of concern, some staff identified that they would report issues if they related to the wellbeing of a colleague or junior doctor, or if they were affecting patient safety. Line managers in three of the six focus groups related experiences in which inappropriate behaviour including bullying and harassment undermined patient safety. Examples include being prevented from gaining access to patients to deliver treatment, being deliberately given insufficient information about a patient, making mistakes as a result of stress, and the dangers of fatigue as a result of unreasonable rostering decisions.

Focus groups comprised of junior doctors indicated a high degree of acceptance of bullying and harassment—such behaviour was explained as a 'training technique' that helped motivate them to work harder, or as unfortunate but an inevitable rite of passage and part of the 'old-school way'. Junior doctors stated that they were reluctant to report inappropriate behaviour including bullying and harassment for fear of repercussions, because of the entrenched acceptance of poor behaviour and because they did not know how to raise the issues. Despite this, junior doctors at the three health services that offer clinical training programs all identified negative impacts of this approach, including damage to confidence, risks to patient safety, permanent damage to reputation, dropping out of the program and even suicide.

The widespread sense of fear experienced as a result of reporting issues is highlighted in the direct quotes from public submissions included in Figure 2D.

Figure 2D
Quotes regarding fear of reporting bullying and harassment

'…feared I would not be believed, did raise it with some people but most of it was covert and implied I was being sensitive, the manager above had also treated me poorly so I feared what would happen if I tried to report it at this level.'
—Public Submission 29

'In [one of the audited agencies], they need to review their management from Team Manager up. Because of the ongoing cronyism and endemic bullying culture, many of these positions are currently filled by inappropriate personalities who control their subordinates through fear of retribution and discipline. Employees currently don't feel safe to complain because the bullying and targeting just gets worse when they do.'
—Public Submission 48

'It is really difficult when you are naming a bully further up the food chain to you, no one else wanted to support my complaint as they had either left or were scared of losing their jobs if they came forward.'
—Public Submission 73

Source: Victorian Auditor-General's Office.

Recommendations

That health sector agencies:

  1. apply a risk management approach to the prevention of and response to inappropriate behaviour, bullying and harassment, including identifying and reporting to the board the causes, prevalence and impact
  2. detail clear responsibility and accountability for identifying and responding to inappropriate behaviour including bullying and harassment within policies and procedures
  3. ensure that their boards use indicators to benchmark positive culture and monitor the risk of inappropriate behaviour
  4. demonstrate to the Department of Health & Human Services that staff feel safer to report inappropriate behaviour including bullying and harassment and believe action has been taken in response to this behaviour.

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