It is a stomach-churning reality that the NHS rests on bullying the people who work in it. This “endemic culture of bullying” has facilitated a growing crisis of structural discrimination and racism, staff burnout and stress, and with it a risk to patient safety.

Getting a perspective on bulling is difficult because it requires facing up to some hard facts of life. Bullying in the NHS is likely to get worse as the financial crisis deepens and, whatever our job, we are all involved in any bullying that takes place at work.

Psychoanalytic ideas can help us understand how bullying becomes established, defining it as a psychological and social defence against our own feelings of vulnerability, anxiety and aggression. Under this model, bullying is an attempt to project our own vulnerability and fear into other people, something that under the right (or wrong) circumstances we are all capable of doing.

This is not to suggest that everyone is actually a bully, but rather that bullying at work is painful in part because we are all involved. Whatever our role – for example the patients that stand by, the staff that turn a blind eye, the politicians that cut budgets and the bullies themselves – we all have a part to play in bullying becoming established at work.

How bullying works

Despite everything we know about the necessity of teamwork in health and social care, where bullying exists we generally don’t challenge it. Common survival strategies include withdrawing from colleagues or striking up alliances with people who offer us protection. This can include establishing gang-like ways of working, such as blaming and excluding people with different views or ways of working.

Gangs, unlike functioning teams, offer a mafia-like organisation where accepting the rules protects you from attack but demands utter compliance. It is a dangerous culture in healthcare, where our duty of care demands we raise concerns about patient care.

Another important dimension to bullying is what happens in the mind of the victim when the bully launches their attack. One of the reasons why bullies get under our skin is because they enlist our internal bullies: the voices inside our heads that actually agree with the external bullies. In the case of health and social care workers, this internal voice can efficiently disorient us and underminine our self-confidence.

Understanding the dynamic nature of bullying in this way – that it has systemic and individual aspects – can feel like an attack on the victim. But it’s a risk worth taking because by understanding the nature of bullying we can start to tackle it.

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Sweat the small stuff

Having had the dubious honour of working on bullying at work for some time, I’m going to do something that I don’t normally do and give you a checklist. It is based on one simple principle: that tackling bullying requires sweating the small stuff and taking some small practical steps.

Step 1: find some higher ground

Being bullied feels like drowning so you first need to get to safer ground. This involves getting out of bullying hot spots. This can be anything from avoiding the smoking breaks or those after-work drinks that seem to end up with someone calling you fat and ugly. Or it can be going somewhere every day where you feel safe, from your best friend’s sofa to the nearby allotment.

Stage 2: bullying book

Methodically write down the times, places and what happened every time you were bullied. Not everything is subjective, there are facts about bullying behaviours so write them down. Keep the book at home and only ever open it when you’re in a robust frame of mind and definitely not when you are drunk.

Stage 3: get a witness

It is essential that you tell someone what is going on. They can be someone that has witnessed the bullying or not, someone you like or not, but someone who you trust to keep their eye on you. Telling someone does a number of things but firstly it forces you out of your bunker and makes you admit what is happening.

Stage 4: phone a friend

Whether you are a victim of bullying or trying to help someone who is, there’s a huge temptation to withdraw from other people. But tackling bullying requires doing something totally counterintuitive: making contact with other people and asking for their help. In a bullying workplace, joining a group can give us a profound sense of place and support to make changes. Trade unions are often good at dealing with bullies and reps can be dogged in their devotion to shouting back on our behalf when we can’t summon up the strength to do it ourselves.

If you can regain your humanity by taking some small steps you will then be in a better position to make the bigger decisions about how to tackle bullying at work.

Acknowledging that bullying is an ordinary part of working life is not the end of the world nor does it inevitably mean you have to walk away from your job. Ironically the strength needed to face up to bullying involves accepting both our power and vulnerability. As any clinician will know, the work of helping other people involves helping ourselves. This turns out to be the hardest part because it requires us to put aside our shame and ask another human being for their help.

This column looks at the reality of our health and care systems from the perspective of those working to deliver services. Please send us your anonymous stories from the frontline.