Bullying and Harassment in the Health Sector

Tabled: 23 March 2016

3 Preventing bullying and harassment

At a glance

Background

Under occupational health and safety legislation, employers are obliged to eliminate or minimise so far as is reasonably practicable risks to the health and safety of their employees. The risk of workplace bullying and harassment can be eliminated or minimised with a range of controls.

Conclusion

Health sector agencies cannot demonstrate that they have responded to workplace bullying and harassment effectively. They do not have a comprehensive understanding of the hazard and, as such, cannot effectively respond to the risk. Key controls are inadequately implemented, missing or poorly coordinated.

Findings

  • Although policies and procedures are in place, they are fragmented, inconsistent, unclear, incomplete and poorly understood and implemented.
  • While some training is available, it is inadequate because it is superficial, ad hoc, largely not mandatory, difficult to access and not evaluated for effectiveness.

Recommendations

That health sector agencies:

  • apply the sector-wide policy framework and approach to prevent and respond to inappropriate behaviour including bullying and harassment
  • ensure compliance by all staff with policies and procedures related to bullying and harassment
  • develop and implement mandatory, targeted training and support mechanisms on the awareness of bullying and harassment, which are regularly reviewed and evaluated for effectiveness
  • develop and implement mandatory, comprehensive training and support mechanisms for managers on preventing and responding to inappropriate behaviour including bullying and harassment, including developing positive workplace cultures and relationships through good management practices.

3.1 Introduction

Under the Occupational Health and Safety Act 2004, employers are obligated to eliminate or, if that is not possible, minimise so far as is reasonably practicable risks to the health and safety of their employees. The risk of workplace bullying and harassment (which includes all inappropriate behaviour) can be eliminated or minimised with a range of controls, such as positive culture initiatives, policies, training and education. A risk management approach involves:

  • identifying the potential for workplace bullying through data and identifying organisational risk factors
  • implementing control measures to prevent, minimise and respond to these risks, such as building a positive, respectful culture and developing good management practices and systems of work
  • monitoring and reviewing the effectiveness of these control measures.

This part assesses these preventative controls.

3.2 Conclusion

The audited agencies cannot demonstrate that they have effective preventative controls in place to reduce workplace bullying and harassment. Key controls that would effectively reduce this risk to employee health and safety are either inadequately implemented, missing or poorly coordinated.

3.3 Policies and procedures

Policies and procedures are not acting as an effective control to reduce the risk of bullying and harassment in the audited agencies. Although each of the audited agencies has policies and procedures in place, some are unclear, have significant gaps or are not evaluated. In addition, our focus groups and analysis of public submissions indicate that staff do not:

  • fully understand the policies and procedures
  • believe the policies and procedures are effectively implemented
  • comply with policies and procedures, despite being obliged to do so.

Policies and procedures should establish clear standards and expectations of appropriate behaviour for all employees and clearly outline staff responsibilities. They should also clearly detail procedures for responding to behaviours that do not meet these expectations. Policies and procedures should be comprehensive and ensure consistent and transparent practice, need to be known and understood, and should be complied with to ensure safe systems of work are being maintained.

3.3.1 Inadequate policies and procedures

Unclear and overlapping policies and procedures

Although all audited agencies have policies and procedures relating to bullying and harassment in place, they are complex and overlapping and, at times, they are in conflict with one another. This is because audited agencies do not provide an overarching policy framework to guide and integrate their organisational approach to managing inappropriate behaviour including bullying and harassment.

An overarching policy framework should emphasise prevention and the value of building positive workplace relationships and culture. A policy framework forms an important link between setting expectations of professional behaviour through code of conduct policies—which have recently been introduced by four of the audited agencies—and the multiple procedures in place for dealing with both early intervention of issues raised informally and management of formal complaints and grievances about bullying and harassment. The current policies and procedures make it difficult for staff to understand the process and are ambiguous as to what response is required and when process steps should be undertaken:

  • Conflicting policies and procedures—one audited agency has five complaints policies, each providing different guidance.
  • Unclear rules and guidance for investigations—investigations are a key part of resolving a formal bullying and harassment complaint, yet guidance for the complainant and those managing the investigation is unclear. Four audited agencies did not indicate the threshold at which an investigation is required, or the circumstances under which an investigation should be undertaken by an external party, while one audited agency did not provide any investigation procedure whatsoever.
  • Inadequate response options for substantiated complaints—one audited agency did not define the possible outcomes of the complaints process, such as disciplinary action, training or termination. No audited agency identified the potential for organisational responses or improvements as a result of bullying and harassment complaints. This highlights the tendency to deal with complaints individually rather than treating bullying and harassment as an organisational OHS risk.
  • Inadequate response options for unsubstantiated complaints—no audited agency identified how it would respond to unsubstantiated complaints, whether at an organisational or individual level. This is a clear weakness—even if a complaint is unsubstantiated, there may be a valid issue to be resolved between the people involved or within the team.
Gaps in policies and procedures

There are also clear shortcomings in the audited agencies' policies and procedures related to bullying and harassment. Gaps include:

  • No or limited information detailing the investigation process—three audited agencies had no information on the investigation process, such as the steps to undertaking an investigation, when it is appropriate to investigate, who should undertake investigations, and that options other than a line manager are available to ensure impartiality.
  • Avenues of support available to staff—three audited agencies failed to identify external agencies that are available to support employees, such as WorkSafe Victoria, FairWork Australia and the Victorian Equal Opportunity and Human Rights Commission. This is significant because the Victorian Public Sector Commission (VPSC) People Matters Survey indicates that the health sector has the highest incidences of reported bullying in the public sector.
  • Required complaints documentation not specified—only one audited agency committed to documenting and recording all stages in the process once a formal complaint was made. This lack of transparency undermines the integrity of the whole process.
Insufficient review of policies and procedures

Only two audited agencies had undertaken any review of the effectiveness of their policies or processes in the previous three years. In both cases, the reviews only considered the effectiveness of the investigation process.

3.3.2 Poor understanding of and compliance with policies and procedures

Staff from all levels across all audited agencies report poor understanding of bullying and harassment policies and procedures and noncompliance, as shown in Figure 3A.

Figure 3A
Poor knowledge, understanding of and compliance with policies and procedures

Issue

Reported in focus groups

Reported in public submissions

Poor knowledge and understanding of policies and procedures

Poor knowledge and understanding of bullying and harassment in relation to the definition in the policy and the threshold, particularly in cases that were less extreme

14 of 17 focus groups:

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

NA

Not knowing how to raise issues or concerns.

12 of 17 focus groups:

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

NA

Noncompliance with policies and procedures

Poor adherence to policies and procedures

9 of 17 focus groups

23%
(19 responses)

Inappropriate behaviour by senior managers and clinicians

10 of 17 focus groups

NA

Failure of leaders to hold senior management and clinicians to account

12 of 17 focus groups

NA

Insufficient action or avenues of address

13 of 17 focus groups:

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

40%
(32 responses)

Source: Victorian Auditor-General's Office.

In three of the audited agencies, senior managers report that clinicians also routinely do not conform to the behaviour expected of them under the health service's policies. Additionally, clinicians including junior doctors rarely raise issues through health services' processes. This is important because clinicians, as leaders in the health sector, play an important role in establishing norms of behaviour. Further, it also indicates the high risk that junior doctors face through the inequality of power that exists between them and supervising clinicians, particularly in relation to performance grading and career progression.

The Royal Australasian College of Surgeons' (RACS) Confidential Draft Research Report confirmed entrenched barriers that prevent clinicians from being held to account. Quotes from respondents include:

'Surgeons are outside of the HR jurisdiction of the hospital administration and are accountable to no one for their behaviour …'

'[The] … reluctance to get involved or to investigate complaints of senior surgeons, and desire to retain hospital personnel takes precedence over the need to address inappropriate behaviour. A recurrent sub-theme is a failure to act, a failure to respond or a response that's ineffectual.'

3.4 Training and education

Training and education can help to reduce the risk of bullying and harassment, but are ineffective at the audited agencies. While some training is available, the audit found that it is inadequate, not mandatory and not evaluated for effectiveness.

Appropriate training and education ensures that workers, including managers and supervisors, understand their responsibilities and have the appropriate skills to take effective action when needed. Managers and supervisors, who are in the front line in relation to effective response and prevention, require the necessary skills to develop positive workplace cultures and good management practices.

3.4.1 Inadequate bullying and harassment awareness training

Bullying and harassment awareness training at the audited agencies is inadequate to build sufficient understanding of the causes and impact of this OHS risk. As shown in Figure 3B, training at some audited agencies is limited to short online modules that are not supplemented by other delivery modes. The training is mainly optional rather than being mandatory for all staff. At some agencies, relevant training has only recently been introduced.

Figure 3B
Bullying and harassment awareness training for staff

Training

Audited agencies offering training

Comments

Bullying and harassment awareness training

5

Online module only—four audited agencies

Not mandatory—one audited agency

Introduced recently—two audited agencies

Raising issues of bullying and harassment and conflict management

0

Source: Victorian Auditor-General's Office.

One of the audited agencies supplements its training with an online coaching tool that supports staff to develop strategies for managing conflict in the workplace.

None of the audited agencies evaluate the effectiveness of the training offered, but four of the agencies collect feedback from participants.

While the introduction of bullying and harassment awareness training is a positive step, six of seven focus groups with line managers identified that online delivery of this training did not provide sufficient information or adequately engage participants to build their understanding and capability of such a complex issue.

Insufficient training for managers

Training for managers in preventing and responding to inappropriate behaviour including bullying and harassment is inconsistent and insufficient. This means that those responsible for intervening early are not adequately trained to do so. Managers play an important role in establishing positive and respectful workplace cultures and addressing issues. It is important that they respond effectively to whatever issues are brought to them, however minor. This is a key control in reducing the risk of inappropriate behaviour including bullying and harassment. Figure 3C outlines the training available for managers across the audited agencies.

Figure 3C
Training, support and resources for managers in preventing and responding to inappropriate behaviour including bullying and harassment

Training

Audited agencies offering training

Comments

Responding to bullying and harassment

1

One-off session for managers in 2015

Human resources department provides support and coaching

4

Ad hoc support and advice to line managers

Management training including performance, providing feedback

3

One audited agency:

  • mandatory management program forall operational managers, but it was a one-off and ended in 2015
  • replaced with non-mandatory units

Two audited agencies:

  • comprehensive suite of management courses including on difficult conversations, managing performance, giving feedback
  • but not mandatory

Additional management support mechanisms

1

Online management coaching service

Guidance including management information cards

Source: Victorian Auditor-General's Office.

One of the audited agencies supplements its training to managers with an online management coaching service that supports managers to effectively address issues brought to them. This is also supported by online guidance and management information cards.

None of the audited agencies evaluate the effectiveness of the management training they offer, though four of the agencies collect feedback from participants.

While two audited agencies have extensive training in good management skills, this training is not mandatory. Line managers at the audited agencies report that training can be difficult to access due to time constraints or limited awareness and availability. Only one audited agency provides training for managers on how to respond to bullying and harassment issues reported to them informally by staff, however, this was a one-off initiative.

The inadequacy of training at the audited agencies is supported by the results from the focus groups of staff and the RACS survey—detailed in Figure 3D. Consistent themes include lack of access to training, recognition of the need for more training and poor capability of line and middle managers (including clinicians) in effectively preventing and responding to inappropriate behaviour including bullying and harassment.

Figure 3D
Inadequate training

Issue

Focus groups

RACS survey

Lack of access to training

4 of 6 line manager focus groups

78.8%
(2 250 surgeons)

Poor capability of line managers and clinicians

14 of 17 focus groups

55.7%
(1 541 surgeons)

Need for additional training

6 of 6 line manager focus groups

33.3–35.6%
(901 surgeons)

Source: Victorian Auditor-General's Office.

The capability of line managers to deal with inappropriate behaviour was also raised as a concern by human resources staff and senior managers in interviews.

3.5 Building positive and respectful workplace culture

Building positive and respectful workplace cultures is a key control for preventing inappropriate behaviour including bullying and harassment. Positive culture and respectful relationships require clear standards about expected behaviour, mechanisms to reward appropriate behaviour, and effective reporting and response procedures to address inappropriate behaviour including bullying and harassment.

The 2012 VPSC report Exploring workplace behaviours: from bullying to respect reported research that identified the importance of workplace culture and context for interpreting behaviour. A key finding was that the levels of trust in the organisation and relationships inform how behaviour is interpreted—the report states, 'employees are more likely to perceive that bullying is occurring where there are low levels of trust in their relationship with the person engaging in the behaviour and in the organisation itself.' This highlights the importance of:

  • encouraging respectful behaviour and discouraging disrespectful behaviour
  • treating perceptions of bullying—as observed in the People Matter survey—as a useful warning indicator
  • building employee trust in relationships and the organisation by modelling the values required and emphasising the importance of the 'how' as well as the 'what' in performance management systems.

In acknowledgement of the important role of culture in this process, four audited agencies have introduced policies, undertaken workshops and conducted training sessions to promote positive workplace values and emphasise appropriate workplace behaviours.

One audited agency has started a cultural change journey that they state will be a five‑year process. The first step was identifying and understanding the problem by gathering and comparing data. This highlighted that issues with bullying and harassment were affecting their reputation and preventing recruitment and retention of clinical staff. The second step has been to develop a response to this problem. The cultural change program is in the early stages of implementation. It demonstrates a risk management approach which aims to prevent inappropriate behaviour by embedding a positive culture of safety and accountability across the agency. One element of this is the Safety Culture Program, which introduces an organisation-wide framework and training program focused on promoting professional accountability in relation to patient and staff safety. The steps they have taken are outlined in Figure 3E.

Figure 3E
Case study: A cultural change program

Step 1—Identify and understand inappropriate behaviour including bullying and harassment

Analyse data and identify themes

The agency sought to understand the problem by gathering and comparing information and data to identify recurrent themes.

Sources included:

  • People Matter Survey
  • Values Review Project
  • Patient Safety Survey
  • needs analysis
  • Medical and Nursing Engagement Survey.

Focus on cultural levers

Analysis of the themes found that the agency's workplace culture needed significant improvement if the agency was to achieve its goals. This required a focus on key cultural levers including:

  • accountability
  • leadership
  • values
  • safety
  • communication
  • change.

Step 2—Reduce and control the risk

Develop and implement initiatives

The agency developed and implemented initiatives including a Safety Culture Program, leadership and values programs and an anti-bullying campaign.

An important element of the Safety Culture Program was the Promoting Professional Accountability Framework. It aims to implement a graduated process of interventions commencing with informal conversations through to awareness raising initiatives and guided and disciplinary interventions for continued infractions.

Step 3—Monitor and review

Identify measures of success

The agency identified relevant measures of success and expects to see a shift in its results in the first three years of the cultural change program.

Measures include:

  • results from the People Matters Survey, including the addition of staff safety culture measures
  • results of the Patient Safety Survey
  • quality and safety performance measures concerning the safety and reliability of patient care
  • decreased occurrence of persistent staff unprofessional behaviours
  • absenteeism reporting
  • retention reporting
  • patient experience.

Evaluate the program

The agency has developed process and outcome evaluation to determine the impact of the cultural change program and its objectives to improve safety culture and promote professional accountability.

Source: Victorian Auditor-General's Office.

Recommendations

That health sector agencies:

  1. apply the sector-wide policy framework and approach to prevent and respond to inappropriate behaviour including bullying and harassment
  2. ensure compliance by all staff with policies and procedures related to bullying and harassment
  3. develop and implement mandatory, targeted training and support mechanisms on the awareness of bullying and harassment, which are regularly reviewed and evaluated for effectiveness
  4. develop and implement mandatory, comprehensive training and support mechanisms for managers on preventing and responding to inappropriate behaviour, bullying and harassment, including developing positive workplace cultures and relationships through good management practices.

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