Breeding ground for bullying? How to stop toxic behaviour in emergency departments
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Breeding ground for bullying? How to stop toxic behaviour in emergency departments

Alison Stacey @alibaabra Senior news reporter

Civility Saves Lives and RespectED aim to raise awareness about bullying and harassment among nurses in emergency departments to help improve work environments

Emergency departments (EDs) are often noisy, busy and overcrowded places. For patients and relatives, the environment can feel alien and frightening.

Emergency Nurse. 30, 3, 6-8. doi: 10.7748/en.30.3.6.s2

Published: 03 May 2022

For nursing staff, the ED can be a relentless grind of stress. And with that stress can come burnout and toxic behaviours, which can create a ‘breeding ground for bullying’.

Harassment, incivility and bullying between members of staff can have a hugely negative effect on individuals and wider team morale. And, as highlighted by the 2013 Francis Report into care failings at Mid Staffordshire NHS Foundation Trust, it can also cost lives.

In partnership with the grassroots movement Civility Saves Lives, the Royal College of Emergency Medicine’s (RCEM) RespectED campaign aims to raise awareness about toxic behaviours among staff, and the simple changes that can be made to help improve working environments.

RCEM lay-chair and leader of the anti-bullying task force Jayne Hidderley describes EDs as the gatekeeper to a hospital, with emergency staff interacting with colleagues in other specialties in their own hospital, and beyond, as they try to refer a patient to the right place.

This can be a source of conflict. ‘More than any other area of the NHS, the ED is a melting pot of different teams coming together,’ she says.

Examples of toxic behaviour, bullying and harassment

  • » Being ignored or ostracised by other members of staff

  • » A colleague physically turning their back on you or walking away during a conversation

  • » Racist, homophobic or sexist language – this may be disguised as ‘banter’

  • » Speaking in a hostile or confrontational tone

  • » Swearing and aggression

  • » Persistent and frequent negative comments about colleagues

  • » Physical violence

  • » Intimidation or threats

Source: Royal College of Emergency Medicine (2021)

Feeling undermined

‘Interactions with other specialties can become difficult and it is a common problem.

‘A nurse may request a neurologist or radiologist to come down to assess a patient and they might be hostile and question their knowledge. It can leave them feeling undermined, demoralised and can lead to conflict.’

One in four (24%) of the 154,000 registered nurses who responded to NHS England’s staff survey in 2020 had experienced at least one incident of bullying, harassment or abuse from a colleague in the previous 12 months.

This rose to 32% of nurses and midwives working in acute settings.

One nurse working in a London hospital told us that a ‘classic scenario’ is that junior nurses often feel as if they cannot stand up to senior staff, as they felt too intimidated.

‘Nurses can feel like they don’t have the voice or the experience to stand up to someone, when a referral is maybe being rebuffed,’ they said.

‘Working in the ED you’re trying to work out who these patients need to see, and often we are like the switchboard trying to get patients to the right specialties and translating and interpreting referral letters.

‘Often calls to other departments are met with antagonism – people talk to you like you’re stupid and sometimes treat you with downright malice. When it’s happening time and time again it can make you feel worthless.

‘You are working in a noisy environment often with no natural light. You are tired, working unsociable long hours with some of the most challenging patients.

‘Not only that, you are battling against decades of historical hierarchy in the NHS, which we don’t find in many other environments.’

University Hospitals Coventry and Warwickshire NHS Trust emergency consultant Chris Turner, who launched Civility Saves Lives with Sherwood Forest Hospitals NHS Trust nurse Denise Guzdz, says that ED nurses are particularly likely to be exposed to hostility and harassment at work.


Picture credit: iStock

He says: ‘Working in an ED can be a relentless grind, a constant revolving door.

‘I remember 20 years ago when you did a night shift, around 4am it would always be quiet. We would get a pile of toast and have a cup of tea, down tools and come together to have a break. Now the pressure is relentless and there’s no quiet time on a shift.

‘This is most of all true for nurses in the ED. And this is because they have almost no non-clinical time.

‘EDs are noisy, they are busy and they can feel hostile to patients or to new members of staff. If people are stressed and tired, then being compassionate or polite might fall by the wayside. It’s understandable.

‘The NHS was already super-stretched – there have been times when I’ve been treating 30 patients in a corridor – and then you bring COVID into the mix and it gets worse. People are knackered and negative behaviour becomes normal.

‘The NHS was already super-stretched – there have been times when I’ve been treating 30 patients in a corridor – and then you bring COVID into the mix and it gets worse. People are knackered and negative behaviour becomes normal’

Chris Turner, emergency consultant at University Hospitals Coventry and Warwickshire NHS Trust

‘But what we have to remember is that we all turned up today to work and we are all doing a difficult job.’

Hold bullies to account

Last year the government published a report on workforce burnout and resilience in the NHS and social care, following a parliamentary inquiry.

Helene Donnelly blew the whistle on poor care at Mid Staffs while working as an emergency nurse at the now-defunct trust.

She says that to retain staff, persistent bullies need to be held to account. ‘To look after our patients, we need to look after each other,’ says Ms Donnelly, who now works as a Freedom to Speak up Guardian at Midlands Partnership NHS Trust.

One nurse’s experience of hostility and harassment

Tom* is an emergency nurse who says he experienced hostility and harassment from a colleague over the course of several months, including the colleague spreading false rumours about him on WhatsApp.

The issue was resolved only when the colleague left to work at another trust.

Tom says the experience affected his working life. ‘I definitely changed my working pattern,’ he says.

‘If I was in charge of a shift, I would actively avoid areas that I’d allocated the person to.

‘On a usual day I would do my paperwork and admin in the office, but if I knew she was on shift I would go and do it in resus or around other people. I would check the rota and try and swap shifts so we weren’t on together.’

Tom found the situation frustrating and demanding: ‘Everyone knew about it. I tried to be professional, whereas they definitely didn’t.

‘Things came to a head when she wanted to have a conversation with me alone. I had to collar the matron to be in the room with me at the same time, just to make sure that nothing was misconstrued or that I didn’t say anything to make it worse.

‘I just wanted to get on with my job, but she didn’t allow that to happen. When I found out she was moving on I was elated, there was an end in sight.

‘As with other people I know who have gone through similar things, there is a horrible unknowing about where and when this is going to end.’

*Not his real name

Mortifying banter

‘Previously bullying, especially between nurses, was seen as playground politics and brushed off by management. Abusive, racist or sexist language was freely bandied about and passed off as “banter”.

‘At Mid Staffs it wasn’t just in the staff room, it was in the middle of clinical areas where patients and relatives could hear. It was mortifying.

‘But when you are short-staffed, depleted and burnt out, you don’t have the time to face it.’

She says bullying can have an effect on patient safety.

‘Unlike other industries, toxic behaviour among staff can affect a patient’s life. So we have to grab hold of that hot potato and act.’

In January 2021, Ms Donnelly told a House of Commons health and social care committee’s session on workplace culture in the NHS and social care there needed to be a new national body to stamp out bullying in the NHS ‘once and for all’.


Picture credit: Neil O’Connor

‘Bullying was seen as playground politics and brushed off by management’

Helen Donnelly, Freedom to Speak Up guardian at Midlands Partnership NHS Trust

She also called for the provision of peer and expert support to organisations that are struggling; and greater accountability.


Toxic behaviour among staff can affect a patient’s life

Picture credit: iStock

‘We have particular individuals and characters who are known to display persistently negative bullying and intimidating behaviours, but they are too difficult to handle so they just get moved along,’ she adds.

Dr Turner says workplaces need to openly commit to addressing any toxic culture.

Steps that can be taken include encouraging staff to watch the RespectED campaign online resources.

‘It’s a tough thing to do to speak up,’ adds Ms Hidderley.

‘But this is part of your culture and if you want it to change, then speaking up against it is the only way. It has to come from the grassroots.’

Find out more

Civility Saves Lives.

House of Commons Health and Social Care Committee (2021) Workforce Burnout and Resilience in the NHS and Social Care

NHS England Staff Survey 2020

NHS Employers (2020) Tackling Bullying in the NHS

NHS Health Education England: Freedom to Speak Up in Healthcare in England e-learning

Royal College of Emergency Medicine (2021) Anti-bullying Campaign to Challenge Toxic Behaviour in Emergency Departments

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013)

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