Bullying and Harassment in the Health Sector

Tabled: 23 March 2016

Audit Summary

Workplace bullying is repeated and unreasonable behaviour directed toward a worker or a group of workers that creates a risk to health and safety. Harassment is treating someone less favourably than another person or group because of a particular characteristic—such as ethnic origin, gender, age, disability or religion.

Bullying and harassment have been shown to have significant negative outcomes for individuals. They can cause serious physical, psychological and financial harm to both those experiencing such treatment and to witnesses. Bullying and harassment can affect self-esteem, mental and physical wellbeing, work performance and relationships with colleagues, friends and family. Significant financial impacts may also result from work absences, medical costs, loss of job promotion opportunities and the risk of permanent disability.

In 2010, the Productivity Commission estimated the total cost of workplace bullying to the Australian economy at between $6 billion and $36 billion annually.

The impacts of bullying and harassment on the health sector are also significant. Research shows that these impacts include high staff turnover and associated recruitment and training costs, reduced productivity through poor morale and demands on management time, difficulties in recruiting and retaining staff, and the potential for significant legal costs and reputational damage.

The prevalence of bullying and harassment in the health sector is not conclusively known, however, recent research suggests it is widespread:

  • In 2013, the Victorian Public Sector Commission's (VPSC) People Matter surveyfound that 25 per cent of health agency employees reported experiencing bullying, the highest of all Victorian public sector agencies.
  • In 2014, Monash University's report Leading Indicators of Occupational Health and Safety: A report on a survey of the Australian Nursing and Midwifery Federation found that nearly 50 per cent of nursing professionals who responded to a survey reported experiencing bullying or harassment within the previous 12 months.
  • In 2015, a prevalence survey conducted by the Royal Australasian College of Surgeons' Expert Advisory Group found that 39 per cent of surgeons who responded to the survey reported experiencing bullying and 19 per cent reported having experienced harassment.

Occupational health and safety (OHS) legislation places duties on employers to eliminate or minimise health and safety risks in the workplace. Workplace bullying and harassment is best dealt with by taking steps to prevent it from occurring and responding quickly if it does occur. Fundamental to this is the need to create a positive workplace culture where everyone treats each other with respect.

This is because bullying exists on a continuum of inappropriate workplace behaviours. Evidence indicates that workplace conflicts or minor inappropriate behaviours can easily escalate into bullying or harassment. Early intervention can prevent this. In addition, minor inappropriate behaviours can cause harm and distress and pose a risk to health and safety and need to be appropriately resolved. The audit focuses on the continuum of inappropriate workplace behaviour which includes bullying and harassment.

Key steps in effectively addressing inappropriate behaviour to reduce the risk of bullying and harassment are:

  • 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 through building a positive, respectful culture and having good management practices and systems including policies, procedures and training
  • monitoringand reviewing the effectiveness of these control measures.

This audit focused on whether public health services and Ambulance Victoria (AV) are effectively managing the risk of bullying and harassment in the workplace.

This audit included AV and four public health services—two tertiary metropolitan health services, one large regional health service and one small rural health service. These were selected on the basis of information contained in VPSC's People Matter survey and stakeholder consultations. The audit also included the Department of Health & Human Services (DHHS), WorkSafe Victoria and VPSC. As part of the audit, we undertook extensive interviews, conducted focus groups with managers and staff across the selected health services and AV, and analysed 82 public submissions.

Conclusions

The leadership of health sector agencies do not give sufficient priority and commitment to reducing bullying and harassment within their organisations. Workplace culture in the audited agencies was affected by poor accountability at multiple levels and by leadership teams' poor understanding of bullying and harassment—particularly the causes, prevalence and impact. There are signs, however, that the audited agencies are attempting to change their workplace culture, to adopt one that does not accept bullying and harassment. This is a long‑term challenge which will require sustained leadership focus and commitment.

The health sector is unable to demonstrate that it has effective controls in place to prevent or reduce inappropriate behaviour, including bullying and harassment. Key controls that would effectively reduce this risk to employee health and safety are either inadequately implemented, missing or poorly coordinated.

No audited agency has an effective early intervention process or mechanisms in place to ensure managers are responding to issues brought to them effectively, or at all. The effectiveness of the formal complaints process was undermined by:

  • widespread under-reporting
  • inadequatecomplaints management systems and practices, including inconsistent or absent record keeping and documentation.

The health sector lacks the guidance and support required to improve its management of inappropriate behaviours, including bullying and harassment. There is poor collaboration between the key sector-wide agencies—DHHS, WorkSafe and VPSC—which is needed to tackle this challenge. The limited exchange of valuable information between these agencies and poor pooling of knowledge represents a missed opportunity to support the leadership of health sector agencies who need assistance to reduce bullying and harassment.

There is an urgent need for stronger sector-wide collaboration to develop evidence-based best practice guidance and programs tailored to the health sector.

Findings

Culture

Inadequate leadership

The boards and executive teams of the audited agencies currently have inadequate governance and oversight of the risk posed by bullying and harassment. Although these leadership teams have a duty of care to their employees under OHS legislation, they do not give bullying and harassment the priority that this serious risk demands.

Insufficient priority

The health sector has largely failed to identify bullying and harassment as a risk or to manage it through a risk management framework. Consequently, agencies can only manage such behaviour at the level of the individuals involved on a case‑by‑case basis. This prevents a clear understanding of the underpinning organisational factors that contribute to inappropriate behaviours including bullying and harassment, and misses the opportunity to collect and analyse data, which could support prevention and continuous improvement across the organisation. Using a risk management framework would help agencies to identify and assess the potential for workplace bullying, to implement control measures to minimise and respond to these risks, and to monitor and review the effectiveness of their control measures.

Failure to identify and understand the hazard

Reporting to leadership regarding bullying and harassment was absent, unreliable or inconsistent across the audited agencies. This makes it difficult for the leadership to discharge their duty of care to employees and manage bullying and harassment as an organisational risk, even if it is made a priority. A lack of good data about the prevalence of bullying and harassment means that the leadership cannot respond effectively or assess whether controls are minimising the risk. Information reported to the leadership was not of a high quality and did not identify or quantify the causes, prevalence or impact of bullying and harassment.

Poor accountability

There was poor accountability for inappropriate behaviour including bullying and harassment within the audited agencies. This included a consistent failure to hold senior staff to account for inappropriate behaviours. Respondents described a 'double standard' within agencies, where some individuals are perceived as 'untouchable' despite widespread awareness of their consistently inappropriate behaviour.

The audited health services also acknowledged their limited effectiveness in tackling the poor behaviour of senior clinicians and they reported facing considerable barriers in addressing bullying and harassment.

Under-reporting of inappropriate behaviour including bullying and harassment

Widespread under-reporting of inappropriate behaviour including bullying and harassment was identified. Causes include:

  • the belief and experience that there is little point in reporting inappropriate behaviours, including bullying and harassment, as the behaviour is not addressed
  • a distrust of human resources departments, who manage complaints of bullying and harassment
  • the fear of repercussions—across all roles and audited agencies
  • ahigh degree of normalisation and acceptance of inappropriate behaviours, including bullying and harassment, particularly among junior doctors.

Prevention of bullying and harassment

Policies and procedures

Current policies and procedures do not act as effective controls for reducing inappropriate behaviours, including bullying and harassment, in the health sector.

Although each of the audited agencies has policies and procedures in place, some are ambiguous while others have significant gaps or are not evaluated. In addition, our focus groups and analysis of public submissions indicates that staff:

  • do not fully understand policies and procedures
  • do not believe policies and procedures are effectively implemented
  • donot comply with policies and procedures, despite being obliged to do so.
Training and education

Training and education can reduce the risk of inappropriate behaviours including bullying and harassment, but they are ineffective at the agencies audited. We found that available training was limited, ad hoc, not mandatory for staff at all levels, difficult to access or was confined to short online modules.

Training for managers in the skills they need to prevent and respond to inappropriate behaviour, bullying and harassment is inconsistent and insufficient. This means they lack good management practices and the skills to build a positive culture and respectful relationships. Those responsible for intervening early before minor issues escalate—a key control in reducing inappropriate behaviours and the risk of bullying and harassment—are not adequately trained to do so.

Response to bullying and harassment

Ineffective early intervention

Senior managers across all audited agencies highlighted that early intervention by line managers in relation to issues staff raise with them is inadequate and ineffective. There is little trust in this process and this is a significant issue.

Early intervention when issues are less serious or entrenched is widely acknowledged as preferable to undergoing a formal complaints process. This prevents escalation and reduces the impact of the incident. Despite this, no data is collected and no process exists in any audited agency to determine whether early intervention is effective or routinely implemented as a first step across the organisation. It is encouraging to see that two audited agencies have recently introduced a requirement to log all incidents they respond to, not just the formal complaints. This mechanism aims to help them better understand the size of the problem in their agencies.

Inadequate management of formal complaints

No audited agency could demonstrate that it responds systematically or effectively to formal bullying and harassment complaints. We identified extensive deficiencies with each step in the process, indicating that formal complaints of bullying and harassment are not receiving the priority or attention they demand. Shortcomings included:

  • incomplete documentation, including missing witness statements, investigation reports and documentation authorising staff termination when this was the complaint outcome
  • complaints files that were not collated or aggregated to allow for analysis
  • inconsistent investigation practices, such as insufficient rationale for decisions which is contrary to procedural fairness requirements
  • limited effort given to addressing the underlying organisational factors that may have contributed to the behaviour
  • failureto provide key information, such as the right of both parties to seek a review of the decision.

Sector-wide monitoring and support

There is insufficient guidance and assistance offered to the health sector to help it adopt consistent better practice in managing inappropriate behaviour, including bullying and harassment. Guidance is either fragmented or not sufficiently tailored to the health sector and the challenges a hospital environment can pose.

Collaboration remains poor between key sector-wide agencies that have a role in the safety culture of the health sector—DHHS, WorkSafe and VPSC.

Neither DHHS nor WorkSafe have developed guidance or provided support to health service leadership—board and executive level—to assist them in managing the risk of bullying and harassment, despite implementing initiatives focused on improving boards' governance capability.

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
  5. apply the sector-wide policy framework and approach to prevent and respond to inappropriate behaviour including bullying and harassment
  6. ensure compliance by all staff with policies and procedures related to bullying and harassment
  7. develop and implement mandatory, targeted training and support mechanisms on the awareness of bullying and harassment, which are regularly reviewed and evaluated for effectiveness
  8. 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
  9. record issues related to inappropriate behaviour resolved through early intervention
  10. with staff feedback, develop strategies to address reporting barriers, and implement and monitor these strategies
  11. establish and deliver a robust formal complaints process
  12. review and strengthen the capacity and capability of their human resources departments to deliver a consistent organisational approach to preventing and responding to inappropriate behaviour including bullying and harassment.

That WorkSafe, the Victorian Public Sector Commission and the Department of Health & Human Services:

  1. share existing and new data and knowledge to better identify the risk of inappropriate behaviour including bullying and harassment and provide support to health sector agencies with poor safety cultures
  2. develop, in collaboration with health sector agencies and relevant parties such as specialist colleges, an effective sector-wide policy framework, principles and approaches to building positive workplace culture and respectful relationships
  3. support the boards of health sector agencies to understand their responsibilities and requirements for managing inappropriate behaviour including bullying and harassment under the Occupational Health and Safety Act 2004, so that public health sector staff receive the highest practicable level of protection
  4. develop and promote a set of indicators that can collectively be used by the boards of health sector agencies to benchmark positive culture and monitor and reduce the risk of inappropriate behaviour, including bullying and harassment.

Submissions and comments received

We have professionally engaged with the Department of Health & Human Services, WorkSafe, Victorian Public Sector Commission, Ambulance Victoria and four health services throughout the course of the audit. In accordance with section 16(3) of the Audit Act 1994 we provided a copy of this report to those agencies and requested their submissions or comments. We also provided a copy of the report to the Department of Premier & Cabinet for comment.

We have considered those views in reaching our audit conclusions and have represented them to the extent relevant and warranted. Their full section 16(3) submissions and comments are included in Appendix A.

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