Avoidable employee harm: Rethinking NHS complaint and disciplinary processes

Paula Redmond (: 00:04

Hi, I'm Dr Paula Redmond and you're listening to the When Work Hurts podcast, which is brought to you by the Association of Clinical Psychologists, the representative professional body for clinical psychologists in the UK. In this series, I'll be covering the difficult topic of surviving formal complaints, particularly for psychologists. I'll be bringing you conversations with brilliant guests, offering their expertise, experience and wisdom on this tough topic from a range of different perspectives.

This is the final episode in this series. I've learned a lot doing this and I hope it's been helpful for you, whether you faced a complaint yourself, supported someone who has, or just want to be more informed and prepared, should it be something that crops up for you in the future. I've covered a range of angles, looking at the research evidence around the impact of complaints on psychologists, understanding the practicalities of HCPC fitness to practice complaints and how best to navigate these, and hearing directly from those who've been through this. To finish off the series, I wanted to zoom out again, broadening the discussion to complaints in the NHS more generally and the organisational and systemic issues related to this. To explore this, I spoke with a team of colleagues in Wales about their groundbreaking and award-winning work on avoidable employee harm within NHS complaint and disciplinary processes. Working at the intersection of psychology, HR and healthcare quality improvement, Benna Waites, Dr Adrian Neal and Andrew Cooper share their insights into the wide ranging psychological and systemic impacts of these processes, not just for the staff under investigation, but also for the managers and HR professionals involved. We talk about the interventions and initiatives they've developed to reduce harm and promote psychological safety in this field and how their work is influencing change at both operational and policy levels. Please do check out the show notes for links to some really helpful resources, including their brand new book, ‘Under Investigation, Transforming Disciplinary Practice in the Workplace’. We kicked off the conversation with introductions.

Benna Waites (: 02:26

So I'm Bena Waits, I'm a consultant clinical psychologist by background. I'm professional lead for psychology, counseling and arts therapies in an Aneurin Bevan University Health Board. And I also run a leadership program along with Adrian and Andrew in Aneurin Bevan.

Paula Redmond (: 02:44

Brilliant, thank you. And Adrian?

Adrian Neal (: 02:47

I am a consultant in psych. I guess the day job is head of employee wellbeing for an Aneurin Bevan University Health Board. Yeah, been doing that for about 10 years. But work closely with Benna and Andrew across a number of projects. I think that the leadership programme and the avoidable harm are the two key preventative focused projects we're working on and have been doing for quite a while now.

Paula Redmond (: 03:13

And Andrew?

Andrew Cooper (: 03:14

Well, hi, my name's Andrew Cooper. I joined Aneurin Bevan Health Board about three or four years ago to develop the Available Employee Harm Program with a particular focus on the application of the disciplinary policy and process. And it's been great working with Adrian and Benna over this time to develop this as really trying to make a difference and perhaps a gear change in how we do things.

Paula Redmond (: 03:39

Great. And maybe we could start actually with just defining what avoidable employee harm is. I don’t know who would like to just say a bit about how you understand that concept.

Andrew Cooper (: 03:51

So we developed the avoidable employee harm concept, really drawing lessons from the patient safety movements. And the patient safety movement established around 40 to 50 years ago, recognised that actually they were causing harm to patients, the healthcare professionals around the world, recognised that they were causing unintended harm, but also avoidable harm. And the recognition grew that there was no negligence or malice, that it was actually down to working in complex systems, that healthcare is complex. We work in systems that involve multiple layers, multiple people, multiple groups and interactions. And it is within all those interactions that sometimes harm takes place. And the patient safety movement started by recognising the potential and the possibility for harm, and then started identifying areas where harm was most prevalent. And then when they were identified to develop an interventions to address them. So that really underpinned our thinking for avoidable employee harm, reflecting on one of some of the things that we do, perhaps through our processes and our policy application that causes avoidable harm to our staff. So we're a bit behind on the patient safety movement, but just starting that conversation around, are there things that we do that causes harm that can be avoided?

Paula Redmond (: 05:20

And I guess the question to kind of all three of you about what it is that brought you to this work, Benna, shall we start with you?

Benna Waites (: 05:29

So I think over many years as a professional lead, I had noticed the enormous impact both on colleagues from within my own service, but also peers and colleagues from elsewhere, the huge impact that investigations and complaints had on people. And often, because in a sense, it's a process you work your way through, but the emotional impact felt enormous for people. And often these were very long and drawn out processes. So over many, many months, sometimes well over a year, you would see people and the ramifications and the ripple effect in their lives were huge. So it had been around for me for a long time, that sense of this really doesn't feel okay. And is there a better way of doing this? And could we approach this differently? Could we think about it differently?

Paula Redmond (: 06:22

Brilliant, thanks Benna. What about you, Adrian?

Adrian Neal (: 06:25

So I guess acute reds. I, career wise, about 15 years or so, I started moving from a more traditional adult mental health role into staff work, did an organisational psychology masters and then kind of moved sideways. One of the, I guess one of the things I got interested in back then was the impact of organisational processes. Not so much disciplinaries or complaints process, but more organisational change on staff, first-hand experience, and a kind of very prolonged, uncomfortable, fairly miserable experience led me to develop that interest even further, but also leave the job I was in. So that was the kind of the driver personally. Landing in a new job, I guess, one of the things as a head of an employee wellbeing service for years and years, a kind of dominant core business was supporting people going through processes like this and others. But, so it's not just my reflection on that, but my, you the entire team, the clinicians and the team feeling like this was a very tricky area because therapeutically, it's actually very challenging to work with somebody caught up in a process, bit like a legal process, recovery tends not to really happen until it's finished. And then there's the whole wider systemic ripple effect, which you don't tend to see in external legal processes, but you definitely see internally when it affects systems and departments and function and ultimately patients care. So for me, on the radar was always it’d be really helpful to do something in that area. And I do also remember a conversation with a senior psychologist not long after I'd started doing some support for a team and they were saying, can you do something about this? And at the point I was thinking, yeah, that'd be great. But no idea. You know, little seeds along the route, you know, and I guess from a wellbeing perspective, the Holy grail is prevention. We know it's damn near impossible, but we know if you can do something systemically and you can make it proactive or preventative, the benefits are huge. So all of these things back in my mind, and then I can't remember the timeline, but certainly kind of five years ago or so, meeting Andrew and with Benna, a conversation developed around, could we do something in this space? What could we, what could we do? And for us, that was the kind of beginning of the piece of work which we're now talking on.

Paula Redmond (: 09:08

And Andrew, what about you?

Andrew Cooper (: 09:09

So my background is a little different. I've spent probably 10, 20 years in marketing and communications. And actually, how do you tell the story of change? How do you understand impact? How do you turn Benna's description of what's happened to somebody through a process, into something that's relatable, understandable, and that can drive change? I've also been involved with the patient safety movement within Wales that recognised the harm that sometimes our treatments can do to patients. And I guess it was the conversation that the three of us had around, is there anything that we can draw from that learning and insight into how processes are applied? So a key part of patient safety movements has been a focus on quality improvement. How do we understand why things go wrong? And in understanding them, how do we develop new ways that can be tested to see if they're tested and they test well, that they can be built into process and scaled up? So I guess bringing some of that insight into that wider conversation of how these processes were impacting people was really the start of this piece of work. And we use the term avoidable employee harm as a bridge between the two. We work in healthcare. Our healthcare colleagues understand the concept of avoidable patient harm. How do we take our non-clinical colleagues involved in management and administration and HR on a similar journey that actually acknowledges unintentionally often our processes can cause harm. So what can we do to mitigate or change that?

Paula Redmond (: 11:03

Sounds like you guys are a dream team with your range of skills and expertise. So, Adrian, maybe I could ask you, thinking about the work that you've been doing in this programme, and I guess you've all mentioned the impact that these processes can have. I wonder if you could give us some more detail around that. What have you noticed in terms of the impacts of disciplinary and complaints processes?

Adrian Neal (: 11:30

I mean, we published a paper about three years ago, I think, which we use as a case study that was reviewed by… or part of the paper was a kind of case study review methodology, so with multiple professional perspectives on a case. You know, that paper outlined a whole range of different scopes of impact. So we, you know, there is the obvious, and saying obvious, it's obvious to us, but actually still not obvious, about the individual impact. We know that, and I think it doesn't, given our audience, won't take too much imagination to kind of appreciate the individual impact, whether it's, you know, someone's impact on their level of anxiety through to, you know, career changing decisions, you know, and lasting psychosocial scars. So I think we know that. I guess what we also discovered is a whole wider range of impacts, most of which are undocumented. There's minimal literature out there. So we know that this causes a kind of cascade. So we often use the metaphor, it's like dropping a pebble in a pond, but we're only really focused on one angle, which is the individual. There's a direct ripple into a team, into a system, be that because of disruption to usually tight knit teams, distribution of workloads, simply by virtue of somebody not being present and nobody being able to talk about it. So things like that, really difficult for teams. Anxiety and fear across team members who then think, you know, what bearing does this have on them? Suspicion and paranoia, you know, quickly follow because people don't know what to say or do. So we know this really wreaks havoc with teams. We also know that people often go off sick either because they are simply not functioning and therefore not safe to work or as a means of getting some control over what little they have. So we know that impacts on capacity to deliver care. And that then ripples out in terms of a wider social, economic and financial cost. I guess more recently we've looked at the impact of people doing the investigation. So we know that even hardened HR and managers will, there will be, which kind of is a bit of a kind of, you know, d’oh moment, of course they'll be affected because this is a distressing, they're exposed to the distress of others. But we also know that people develop ways of coping with that over time. But we know that even hardened professionals struggle with this stuff and how they cope often doesn't help. They will often cope in ways we know. People will seal over, will harden. It doesn't make them better, having done this for years. But of course, that professional group has no history or tradition of psychosocial resources to support them. So they are pretty vulnerable, frankly. And you could argue, therefore, vulnerable to making mistakes. So that's another area we've noticed. We know that it affects the person who's being investigated's family. That's often not accounted for. So there's this wider kind of arc of impact that happens once you start asking the questions. And what we were surprised with when we started doing this research is there's very little out there. A kind of rapid evidence review a couple of years back, and it's really poor. There's nothing out there and it's not consistent and it's not great quality. So this is a, wow, this really is, if the patient safety movement is kind of 40, 50 years in its evolution and things are still happening, you know, errors are still being made. People's relationship to accepting errors and embracing learning is still very much alive in the patient focused areas. We are way behind, in the human process is just so… you know, parts of our businesses. So yeah, lots of work there.

Paula Redmond (: 15:37

Yeah, I can really relate to all of that you're saying, Adrian. And I mentioned before we started recording, but I was part of a disciplinary process when I was working in the NHS as a witness, supporting witness. And it was for sure the worst, absolute worst professional experience of my life. And definitely one of the worst, you know, top 10 of my life, you know, and still those psychosocial scars that, you know, are still still present for me and just as being a witness as part of that. So I can for sure, yeah, relate to that. Was it Benna, was there anything you wanted to add?

Benna Waites (: 16:15

I think in relation to the individual impact, although I think that's easier to see, I think historically we've massively underestimated that, underestimated the harm. So purely at that level, just to be clear that the harm, as Adrian was saying, goes across multiple systems and areas of life. So kind of professional, reputational, financial, physical health, mental health, social life, family life. So it sort of spreads out across all of those systems, but also just the extent of it. I think what became increasingly apparent to us as we started sharing our experiences of being alongside people in this work, that sense that people are really traumatised. I mean, you can do an impact of event scale and you can score really high for PTSD as a result of going through a process like this. And that's important. You know, I don't think that's widely understood by HR colleagues that there are those kind of costs and they last, they don't stop when the investigation stops. They can last for years and years afterwards. So I think it's just really important. And I suppose that that leads us into the work around how we might avoid that. But I guess really important to understand that when you embark on those kind of processes, and sometimes they're unavoidable, sometimes there's nothing you can do about embarking on the process, so a complaint will be, a patient complaint would be a good example of that, although I think you can be thoughtful at the beginning of that. But in terms of our internal disciplinary grievance, those kinds of processes, those are the areas where we need to be really careful about what our first steps are and what we think an appropriate response is to a set of concerns or difficulties or challenges, because I think we get it wrong all the time.

Andrew Cooper (: 18:12

I think to pick up as well in terms of Adrian's comment, in terms of the impacts on the investigator, that actually when we started this, was very much as Benna’s just set out, the individual who was the centre of the investigation, that's where the red flags emerged, that's where the concern was. But as we've developed this work and taken hundreds of HR colleagues and managers through our training, almost every training event, somebody will come up to me or one of us and say, I've actually been harmed by this process myself in terms of in that investigator role. And we've really looked to understand and explore that a bit more. What does that look like? Where is the harm? And just recognising that investigators are often carrying the workload of an investigation alongside all their other commitments. There is not enough space created for them to do it. The level and the information that's being shared with them can often be distressing. They often see the impact of the investigation lived out on a daily basis of the person they're taking through the process. So all those elements add up to a real sense of impact on the investigator. The paper we had published recently actually highlighted that no matter how many investigations an investigator does, it still doesn't equip them to mitigate the harm to the person going through the process all themselves. So you actually, you bring that into consideration, and I guess we spent increasing time there because if there are to be improvement, it is about understanding that impact. Because I think there is a real sense that if an investigator, the more investigations they do, there's the real potential for desensitisation because what they are presented with is so traumatic themselves and in a sense, how do they manage and regulate themselves in that space? And then I guess if desensitisation is one of the outcomes, that can quickly lead to compassion fatigue. So we believe a good investigation is absolute diligence to process, process is there for a reason, but also managing the wellbeing of the individual being taken through it. And there's real concern that actually if we don't look after our investigators, if we don't create a sense of an opportunity for them to debrief, to understand what they've gone through, then actually it's going to be a downward spiral in terms of subsequent investigations that are taken forward. And I guess for us that was one of the big learning points that wasn't even on our radar when we started this work.

Paula Redmond (: 21:11

Thank you. So I wonder, maybe if you could talk us through the work that you have done and what changes you've sought to make and how that has unfolded?

Andrew Cooper (: 21:21

So we've taken a quality improvement focus with this work. And one of the key things within quality improvement is to look at the data. What is your data telling you? And our HR team conducted a review of investigations that had taken place over a 15-month period and discovered that of the 109 that had been undertaken, over 50 % of those had led to no sanction. So we were putting individuals through a process that we increasingly knew to be harmful, where actually looking at that data, perhaps they could have been taken through a more informal process, which would have addressed issues without the related trauma that we've been experiencing. Second element around quality improvement is to look at what interventions that we need to build to bring about change. And our HR colleagues have done an amazing piece of work within this space. They actually looked at what they call their initial assessment document. So that was a document that managers use to summarise the issues that might lead to an investigation. And they realised that in an earlier version that they weren't collecting all the right information. They were collecting the information related to the issue, but perhaps not the wider context issue. So what was going on in the organisation at the time, who was the person sitting before them? What was their record like? Was their PDR and training up to date? So I actually looked at how do we improve that decision-making document that would consider those mitigations and not just focus on the issue. And then again, HR colleagues have done a job around coaching managers to help them understand the options for addressing workplace issues. Some managers had said to us, well, we thought the disciplinary policy was the only policy to pursue. And we actually were able to highlight, no, there's less formal ones that they can pursue and also help managers understand what are the mitigations that might lead to making a different decision. So I guess there's data, there’s building interventions, and it's working with colleagues in the system who are responsible for making those changes and also helping them understand why those changes need to be made.

Adrian Neal (: 23:54

And if I could just come in there, I think there's a bit of context as well, which is helpful to frame what Andrew has just explained. So I'm sure Andrew wouldn't disagree, one of the reasons we've been able to do this work, certainly because there was internal interest from HR in being curious about the numbers and the disproportionate amount of numbers and certainly the outcomes. But actually, even before that, what we had is we've had kind of the work authorised by the director of workforce. And actually, we started to develop the ideas with the previous director, who then retired and was replaced, and luckily, we had continuity of support, which has only grown. But a key area of support was an acknowledgement, and I still kind of think this was a key point. So my manager, the director of workforce, a kind of career HR, operations HR professional said to both Andrew and I, you know, I, this is uncomfortable, this idea, but I recognise it and I've done it. And that still is a really important moment, I think, in giving us permission to proceed, that recognition of the discomfort the profession has. And we can come back to that point later, I think, as we're looking at it, you what's turning into us, into a bigger culture piece beyond our organisation, but was a kind of cornerstone moment where a senior professional in a NHS role, which is highly politicised, Wales is very political, said, yeah, this is a problem and it's uncomfortable. And to me that helped us immensely because each, as we, as you know, every colleague we talk to now, I think has their own moment of discomfort around this. And that's pivotal for change. But centrally it authorised us to do this work within our organisation because, and I also think you know if we if we'd started this conversation a couple years before it wouldn't have got off the ground, so there was something about timing and the right people were opening the right doors to allow this to happen.

Paula Redmond (: 26:06

Benna, I know that you've got a particular kind of interest around psychological safety in particular and I wonder what that brings to this work?

Benna Waites (: 26:15

Yeah, so I do. I've been teaching psychological safety on our leadership program along with Adrian for 10 years. And I now appear to be doing a PhD in psychological safety with all that spare time that I have, but it's a real interest of mine. I guess part of the reason it's of such interest to me is that I think in health teams that I see around me, it's an enormous problem. There are lots of structural issues that make getting a climate where people can really have a voice and people can speak and raise concerns and ideas and feel connected, it feels a real challenge to make that happen. And of course, what we're talking about, so engaging in formal processes, will make that so much worse. It will have a huge impact on not just the person and their voice and their ability to feel safe in that team, but also on colleagues and it's really interesting you saying earlier Paula that you've had an experience of being part of an investigation. So often these investigations involve interviewing multiple, sometimes tens and tens of people to gather witness evidence. And that whole, that paradigm really of investigation, which feels for most of us, I think in our heads belongs more in a kind of criminal type context sets up, it is a massive counter influence to anything that would support and generate psychological safety. So it can be really challenging. I think if an investigation were done incredibly well and held really well and supported really well, you might be able to create enough safety for people to feel that they've said the things they need to say. I think it is not impossible that those two things can't go together. But most of the time, I think the experience of it will be that it is suppressing of voice. And what we know about psychological safety is that when you lose voice, you lose team functioning, your teams just don't function so well, your performance goes down, all the outcomes that you want, patient care suffers, all of the outcomes you want to see in healthcare get worse when psychological safety is damaged.

Paula Redmond (: 28:35

I think it's also, I mean, my experience was one of, you know, sometimes it was scary, like really scary in lots of ways, in ways that I never expected that it would be. And that thing of, as you say, feeling like you're part of some kind of criminal investigation, but you have to go to work every day and be with people and just the impact of, you know, you want to avoid maybe conversations because it's awful, you know, patient conversations, because to go and be in a room with people and all this stuff is going on and, you know, we don't know who knows what and what, you know, it's just, yeah, really horrible.

Benna Waites (: 29:16

Yes, really, really messy and, and difficult. And so often I think a lot of these processes emerge in environments where there's… that are interpersonally very complex. There's a lot of dynamics flying around and often lots of claims and counterclaims. And I think we really need to ask ourselves, you know what, if we recognise that, what is the best way of addressing and supporting? And I think there is value sometimes in bringing external support and external eyes on the challenges that teams are having, but whether those external eyes should be coming with their sort of tick box investigation kind of lots of questions, sort of gathering evidence, whether it should look like that, I think is really questionable.

Paula Redmond (: 30:03

And what are the other things that you have sought to change in this work? Things that you haven't mentioned yet?

Andrew Cooper (: 30:11

One of things that we've been doing within NHS Wales, so within NHS Wales we've got a once for Wales policy approach, so the NHS Wales disciplinary policy is for every organisation within NHS Wales and about two years ago we started a journey to review it, but also for it to be informed by this work, by this research, by the insights that we were drawing. Interesting that Adrian talked about a piece of research that we did where as part of this disciplinary review, we didn't want to just tweak the policy, we actually wanted to understand what does good policy look like in this space, you know, what does good process look like, what does textbook approach to run disciplinaries look like. So we undertook a rapid evidence review of key HR literature. And as Adrian mentioned, there is so very little out there. And if you pause and reflect and think, actually, we are running thousands of investigations every day around the world, and yet there is very little evidence that suggests what good looks like, I think it’s a real challenge to the profession, but also to all of us involved in either supporting or running investigations. And that curiosity and that need to try and identify the best way of doing things is really critical to this work. I guess, because we're so linked and connected to healthcare, we know that if there's a healthcare issue that arises very quickly, we'll have academic colleagues around the world taking it apart, seeking to understand it, testing medical interventions to address it. And yet we don't have that same approach for processes that seismically can impact populations. And then actually that's the journey that we're on at the moment is, whilst we started with very much an individual impact, how do we understand policy design, policy development, policy implementation to actually improve this? And I guess one of the things that we've looked at is how do we support the individual going through it better? Because actually that's good for them, but it's also good for the investigation. Actually, if we looked at the investigation more positively and said, this is an opportunity to perhaps improve or correct something about how our organisation operates, then we also see the person being investigated as part of that solution, and actually taking them on that journey, looking after them, ensuring a really good duty of care should be an equal part of that process. When Benna was talking, I was reminded of Deming who said, a bad system will break a good person every time. And that actually, you know, you replace that word, a bad process will break a good person every time. And whereas perhaps a couple of years ago we were thinking that person who's broken is the person at the centre of it, the list is growing in terms of, and Paula you've identified that, the list is growing of the people that will be harmed and broken by it. So it is very much how do we step back and really understand how to deliver these things better.

Adrian Neal (: 33:52

Just to build on Andrew's contribution. So I think there's a pivotal idea here, which I think threads through so much of how the NHS as a kind of massive bureaucracy operates and how it responds to individuals versus system factors. So one is from a, I guess a quality improvement or just a systems learning process. We know we're not very good at learning. Why is that? Every inquiry kind of repeats the same thing. So how, why do we struggle with learning? But also, so to me, one of the harms is failure to, each of these investigations, unless you really understand the systemic factors that have contributed, of which it's more than likely to have contributed some way because of the complex nature of our work and also the kind of interactive multilayeredness of how most people work, you never find out actually why this thing happened. Whether it's a complaint, the cause of the complaint or whatever, why the relationship broke down. So it never gets really reviewed and repaired. We just kind of amble on. But as part of that kind of, maintaining that process, which I've always been uncomfortable with because it is just a massive waste, but the airline industry’s going yeah, it's the pilot again, just sack them and let's move on. We need to know why, whether it's a drug error, whether it's complained about, you know, alleged poor care, there’s always going to be more than an individual involved. In our leadership program, we have a colleague who's influenced us all quite a bit, but his kind of model of leadership is a systems leadership approach. And he tends to say, look, most people are not mad, bad or stupid. So why do we keep blaming the individual? I think certainly in the NHS, a lot of the process is designed to target individuals. I don't think it's intentional either. I think it's just culturally, habitually, how these processes end up. But it's also the same from a wellbeing point of view. We know up until fairly recently, it's really just been, well if somebody needs some wellbeing support for the individual, that's possible. I mean, even now that's questionable because of cutbacks. But the support for individuals is much stronger than support for systems or the ability of systems to learn. Burnout is a system problem. So all of these things. So we're working within the space of trying to shift things away from the individual to support learning. And it's going to certainly outlive me. But this is why we think this is the beginning of this journey. There are layers of relevance, I think, that take us into other motivations. But certainly one is this big idea about trying to create work, trying to create an optimal environment in work. And this is certainly, you know, it touches on psych safety, it touches on our capacity to learn, it touches on systems being able to understand people's needs, as we would want to understand patient needs. And we're still getting that wrong sometimes. So I think we are definitely very early days, but it's very exciting.

Paula Redmond (: 37:07

And what have some of the outcomes been? Benna, maybe you can…

Benna Waites (: 37:10

Yeah, so a couple of areas where I'd say some quite concrete things have happened. So one of the things that was really clear to us exploring experiences of being investigated is that predictability is a really significant factor. So we know, and it's basic undergraduate psychology, that predictability and control are the two kind of key mitigators really for stress and in fact social supports, and of course we know that people, because of the shame that often goes along with investigations and the requirement not to talk to any of your work colleagues. So very often people are absolutely deprived of social support. They've lost all control. The one thing that potentially if you're going through a process like this, you could hang on to is predictability if you did what you said you were going to do. And what we've noticed is that so often these processes are set up with entirely unrealistic time expectations, and people don't deliver and they don't do what they say they're going to do. And that's often because investigators are overwhelmingly busy and have got loads of other things going on, but understanding the impact that that has on the individual. So Andrew, Adrian, I don't know if you want to talk more about the guide, but it feels if the guide that we've put together for HR professionals leading these kinds of investigations and also for people undergoing them, is a kind of helpful just building that sense of the understanding of the process, trying to make it a bit more predictable, trying to mitigate a little bit if you are in a position of having to go through it. So I don't know if you, Andrew and Adrian, if you want to pick that up and say a bit more about the guide.

Andrew Cooper (: 38:55

So as part of the review of the disciplinary policy, we actually wanted to think about how do we support individuals better going through the process. And as Benna has mentioned in terms of predictability, it's a key thing that often colleagues report after meetings changed, being advised that they'll get an outcome on one date and then it gets cancelled and dropped. And each one of those experiences, whilst might be an administration factor for the individual leading the investigation, for the individual going through it they are crushing blows each time, because actually they are living their lives waiting for feedback. So we worked with HR colleagues, wellbeing and occupational health colleagues to identify what were the top 25 questions that people ask when they are being taken through an investigation process. So we looked at them on multiple levels. They could be questions like, am I going to be paid while I'm taken through this process? When you say I can't talk to anybody, do you really mean I can't talk to anybody? When this is over, what about when I come back to work? What does that look like? What will it feel like? And I guess what we were looking to do is that if we could provide answers to some of those fairly straightforward questions, it could minimise or mitigate some of the anxiety. It was never going to remove all of it, and you could argue to how much it removes, but actually we had a sense that it could manage some of that anxiety. So the aim is when we launch our policy, that that guide will be issued to everyone who receives the letter telling them that they are now the subject of an investigation, here's the policy, but here's the guide to help you through it. Because in terms of the process, and Benna would be able to kind of advise more on this, but we know that an individual's cognitive ability is reduced during times of stress and anxiety. So their ability to read a complex document like a disciplinary policy becomes even more challenging. And again, the reason that we wrote this guide, we took the model of a patient information leaflet that recognises that when a patient receives a diagnosis, they often remember very little of what the healthcare specialist has said to them, and that's where a guide might come in from, like Macmillan Nurses to say, these are some of the questions you might have. And again, it feeds back into that piece of, we want the person to be in the best place they can be for themselves, but also to contribute to the investigation process well.

Adrian Neal (: 41:53

Just to add and correct me if I'm wrong, Andrew, but you, didn't you do a piece of work looking at the reading age of the previous policy and what was the reading age?

Andrew Cooper (: 42:04

So as part of the review of the process, we had the current disciplinary policy reviewed and were told that actually you had to be at a graduate level reading age in order to make sense of the policy. And as I've mentioned in terms of cognitive ability, that is significantly reduced when we feel stressed and anxious. So in one sense, the policy wasn't necessarily the best document to help somebody through the process, which is where the guide came in.

Adrian Neal (: 42:34

So even in how we convey these ideas, be it formal policy, right down to individual letters, think that it's all, you can create interventions at multiple levels. And often you need to, because it's kind of the failure to understand how people process information is just, it's endemic. But I'm pleased to say that at least within, well, we know that within Aneurin Bevan, and within a number of organisations we've worked with, they've looked at that set of very tangible things they can change. But the guide is, I think, is a key piece of work, just to help mitigate that sense of lost control and kind of social distress around this thing is happening to me. But only mitigate, can't remove those things you need to look at.

Paula Redmond (: 43:25

And Benna, I know you've been, one of the things that's been important for you in the work is thinking about suspension in these processes?

Benna Waites (: 43:31

Yes, there's often a presumption, I think, in these processes to suspend. Often that's kind of part of the process that you follow. So a complaint's received or a process is initiated, and the assumption is that you suspend, and to send somebody home. And I've seen that happen so many times. And I think what really struck me about that was it feels really punitive. It feels as if it increases the impact because suddenly we know don't we the impact of unemployment for example on mental health, we know it's pretty catastrophic for your mental health to lose all structure but to lose all structure at a time when your whole professional identity, your work life, your financial security, when lots of things feel like they're on the line that's really hard to do that. I think there are times when, because the interpersonal dynamics are so enormously complex, that it's better for everybody, including the person at the centre of the process, to be removed. But there are options around finding other places and other opportunities and other ways of working, really. So I guess there's something about fighting the presumption to suspend. But what I've noticed when I've been involved in those processes, is how hard I've had to fight, you know, and even now, you know, even relatively recently in our organisation, it feels as if that's still, I think it's almost baked into HR training, that sense of, this is your starting point, just take everybody out of the situation because that will be better, it will be kinder. And it is messy. Paula, you talked earlier about that experience of being a witness and then having to have a conversation with somebody, those things are tricky. They're really tricky, actually. And I think there are ways you can manage that. So it might be that, you know, somebody's going through a process and there are bits of their job they continue to do, but you know, bits that they don't, or as I say, you can shift them into a different role. But I think we shouldn't underestimate the enormity of removing somebody's occupational structure from their lives at a really stressful time. I just think it's a very damaging thing to do.

Adrian Neal (: 45:50

I completely agree. I guess the other, and Benna alluded to a little bit, I think there's something about how, and this is possibly a healthcare professional specific, but probably not. I suspect other industries have the same thing, probably education. But in terms of people's relationship with their work and their identity and their sense of who they are, their sense of self is often intertwined with their work and with their sense of purpose and those they work with. So I think what at one level might look like an operationally neat thing to do to remove the person from the stressor, it's never neat and it's never straightforward because often people's working environment and their relationships with them is hugely protective. I think that can add a dimension which I think a lot of HR colleagues don't get because they often haven't been through it themselves, but also they may have a slightly different relationship with their work, although that may be unfair. So I think the, and if you, the more complex and messy the situation, often the simpler the solution is really, not a simple solution because of conflicts and the intense expressed emotions, but yeah, so the suspension idea is a fix is really flawed. This has to be an absolutely case by case decision. And I do worry that sometimes less experienced HR colleagues don't feel confident enough to sit there in the fray and not make a reactive decision. I've certainly seen more experienced colleagues able to sit there and tolerate the not knowing and the pressures from different angles. Because again, our work is very politicised, isn’t it? We sit in, HR colleagues often sit in the middle of competing social groups, got pressures often from patient safety angle, legal pressures often. So it's a hugely distressing position to be in. So being able to tolerate that, I think is key. And I pretty much guarantee nobody gets any training on how to do that if you're an HR professional, whereas clinicians, psychologists might, but don't always.

Paula Redmond (: 48:08

Yeah, it's a sort of that, I mean, it's a literal exiling and shunning, isn't it, of, which is such an absolute kind of primitive, and scary for the people left behind too, that someone can be ripped from their midst and we can't know. And yeah, that's really...

Andrew Cooper (: 48:27

I think for me though, as we kind of talked about that impact of suspension and clearly a major one, but Adrian's just touched on, just that difficult space for HR colleagues to inhabit. And I think I've certainly had an increase in appreciation for that. So in terms of where they are perhaps in their career, so often if you've got young HR professionals who have probably been trained and kind of driven into them, you follow the process, you follow the process. And because of that anxiety of kind of coming new into a profession, you do what you're told. And it is only often seen with those colleagues who have more experience that perhaps understands the process better, perhaps have got some experience of how it's impacted, and that they've got perhaps a greater sense of autonomy in order to question and challenge and kind of all within that context of an organisation's appetite for risk, all around in terms of changes in legislation, you know, granting more rights to the employee and that's right, but at the same time, it makes that pathway much more difficult to navigate. So, you know, certainly with this work, it's been very much seeking to appreciate and understand what our HR colleagues and managers, because managers often don't often feel confident to apply policy because they may not do it very often. And because they don't do it very often, they become more rigid in their approach. And then how do you help a manager balance that focus on process and the person. So this journey has really been, actually, how do we appreciate, understand and take our HR colleagues and managers on this journey just because of the challenges that they face in doing it.

Benna Waites (: 50:34

What you were saying, Andrew, reminded me that another area where I think we have quite a significant skills deficit in our organisation, in our healthcare systems generally, not just in our organisation, is around having difficult conversations. And what I notice is that that ability to be able to engage with tricky, difficult, interpersonal concerns is just not really present in our leaders within healthcare. So we've been running a having difficult conversations session on our leadership programme, and it's consistently the one, or it's consistently one of the ones that's right up there, we cover a lot of material, but it's consistently something that people come back to and say, oh, thank, that was so helpful, so useful to think about how I might frame it, think about how I might approach it. But I've noticed over the years when I've perhaps expressed concerns about some of the things going on in a team where perhaps I've done an exit interview with somebody and they've raised some informal concerns, they don't particularly want them to go anywhere, but I'm kind of thinking this would be useful for a manager to kind of hold and think about, and think about how it might kind of shape their interactions with a particular individual. And I've often had a kind of rebuttal from managers saying, well no, if there's no formal process, there's nothing, there's nothing I would expect to do about it. And that feels like a real problem. It's like, this is such a missed opportunity. If we can be catching these things by having the more uncomfortable, the slightly more challenging, the slightly trickier conversations sooner. So that's something that I think connects well to this issue of prevention too.

Adrian Neal (: 52:16

Just picking up the management leadership pattern really, and I'm sure Andrew will agree, so they are, I think, the key group. We talk about HR colleagues, but actually the vast majority of people that will make the decision whether to proceed with a complaint or a professional conduct type of investigation will be the managers. I think management in the NHS is an interesting one in terms of capability, competence, but also how we design our systems. I think we can often, I say, I keep saying this as a generalisation, but often you find managers that are not supported, not educated, and then not developed in very influential roles with a lot more people than they can manage. If you think about how many, you know, what's the ideal size of a team? We know, you know, Aston model would say, you know, 12 to 14. We regularly come across people in the leadership program, they have more than that, way more than that. And how can you be a manager in that kind of system? And if you get a complaint or something coming in, it suddenly takes up so much more of your time. You're more likely to be more transactional about it because you just don't have the capacity to deal with it. That's even before the areas around difficult conversations, which is the upstream stuff that might help prevent these things happening. So I think that as a professional group is, I think we have a real problem, not because there are bad managers, but because how we go about supporting, developing is systematically problematic, because I think it's an almost impossible job. You can skill, you can support. One of the things we noticed in our leadership program is that often, the cohorts will stay together as a resource for each other because they're all struggling with similar things. So again, if you're trying to influence people's experience of complaints or grievances or the managers are pivotal. And I know there's currently a GMB union push to accredit management looking at some sort of accountability mechanism. I can see the logic, but I'm not sure that's the right tool, but I think the accountability is a major part of the problem, as well as the support and the development of that professional group, given that most health professionals are regulated up to the eyeballs, professional managers aren't. And neither are HR colleagues for that matter. So it's interesting. I think there is space in that area to think about that in a useful way, not in a punitive or kind of controlling way, but how do we quality control and support and develop those groups?

Andrew Cooper (: 55:06

Last comment from me on it, but it picks up the psychological safety piece that Benna was talking about, that often when we work with managers and we ask why have you initiated a process? Then it'll often be fear, because the fear of getting it wrong, or fear of not following process because actually this could impact on them. So that sense of around that cultural impact, how psychologically safe a manager feels within the organisation also determines the course of action and the way in which they will commission and lead an investigation.

Adrian Neal (: 55:48

I couldn’t agree more.

Benna Waites (: 55:50

Absolutely.

Paula Redmond (: 55:51

Any other kind of key outcomes or challenges that you've faced?

Adrian Neal (: 55:57

Definitely no challenges.

(Laughter)

Andrew Cooper (: 56:02

I'd almost like to pull Benna in on this, but we've taken this quality improvement approach so that the focus has been for 30 months, two years, how do we improve the approach. But, Benna, we know with improvement, don’t we, that it needs to have that constant focus on it and as the priorities come in, staff change, and I guess it's how we keep the focus on a major cultural change piece because we know things don't change overnight. It needs years of a consistent approach to bring about that change. So I think that's probably more of a longer term challenge, what we feel we've been able to do here is raise it as an issue, identify the related harms and impacts, develop an intervention that might address it. But the long-term challenge is how do we bring about sustained change and not slip back into old ways of practice or if that psychological safety within the organisation is not strong, how do we keep people on that journey of change? Benna, any thoughts?

Benna Waites (: 57:25

Adrian's got his hand up, so let's go to him first.

Adrian Neal (: 57:29

Lots of thoughts. So in me, I guess thinking aloud, there's two spheres of work. There's the operational sphere, which is about individual systems, looking in detail at how they deploy, run, evaluate and understand these processes and how they can be used internally to help improve learning and to kind of navigate some of these very real psychosocial challenges and minimize harm. So that to me is one thing, just good business. At the other end, there's the idea, and I think that's slightly more linked to the cultural dimension, so the avoidable employee harm idea. So it's interesting because I think you get dissonant, you get people who go, yeah, no, this is, I can't not think of this idea now. And then you look at the data and they still, you know, there's still problems. So I think there's, how do you keep both alive? Because they're not necessarily, they're interconnected, they're, and they're both necessary. But one of the things I'm, and Andrew will know this, but I'm gonna say it out loud, I'm particularly proud of is the two pieces of work. One is the policy work, national policy work, because if you're gonna get anything to stick, that's the way to do it. And I think Andrew could definitely tell you how fun that's been, but it's gonna get over the line. And the second piece is another piece of work Andrew has been working on, but it's to establish an avoidable employee harm award category within the HPMA UK. So the idea that it's so legitimised now, a national organisation for the accreditation of healthcare management professionals has created an award. So the idea that is so valid now that that organisation is taking it forward at that level, I think will help keep it in people's minds. So that I think will seed, but we also need that on the ground, operational changes. And that I think is… both are challenging, but both are moving. I'll stop talking.

Paula Redmond (: 59:33

Thank you. Benna?

Benna Waites (: 59:35

So picking up on Andrew's point about sustaining gains, I think that's a real challenge. So we saw some really incredible results of this work being picked up early and a reduction in processes and of course, all of the kind of harm we avoided and all of the time we saved, which is fantastic. But trying to keep that as Andrew says, when you get change in personnel and shifts. So that sustaining your gains is an ongoing challenge, I think. The issue about how we design the culture, how we create a culture that will prevent or massively reduce these kind of processes, feels really important. And I think there's lots to be done in relation to leadership, because leadership, I think, has such a huge impact on the climate in teams, but also on the way that we talk about our work, the way that we think about our work. So another… Adrian was referencing our colleague Ian McDonald earlier who works in systems leadership, but Ian would talk about what's the work and I think that sense that the work of leaders, the work of teams is to create an interpersonal environment that is psychologically safe, that works for everybody in it, that enables concerns and difficulties and disagreements to be explored safely. That is a really key part of our work and I just don't think we give it the air time. And I think I'm really interested and we have done less work on this, but I think we will do more. Andrew mentioned the kind of to-do list that we have and are working on, but something about the sort of postvention that kind of aftermath, the sort of return to work, the, you know, what happens afterwards. And that feels really important in terms of how you might restore connection and psychological safety after a process. So it feels like there are lots of challenges and opportunities around this work. It's yeah, it's just finding the time to do it all really. But yeah.

Paula Redmond (: 01:01:40

And can I ask a question, I'm curious about the… Adrian and Benna have been clinical psychologists in this kind of space that's fairly unusual for most psychologists to be working in this way. What do you think you bring sort of uniquely as clinical psychologists to this and how has that been received, particularly thinking about the HR kind of work?

Benna Waites (: 1:02:02

So my sense is it's been absolutely welcomed. I think it's been really well received in the main. So I, you know, Andrew, you and I did a session, didn't we, in North Wales, and I was really struck by how grateful people were. I think that discomfort that Adrian described earlier, that sense of discomfort about there is something wrong here, I think is really widely recognised. And so I think there is a real appreciation of people bringing, shining a light on that and trying to think constructively with people about it. I think we've tried really hard, we may not always succeed, to understand the context that these things happen in, the context for people's training. So I think there's a really deliberate effort not to be critical and not to be, but just to say, look, can we all think about doing this differently? So my sense is that broadly it's been welcomed and I think that will be backed up by some of the awards, some of the acknowledgement, some of the kind of publicity that we've had in that world specifically of HR. So I, my sense, it reminds me a bit of across my career, often as a psychologist in a system that doesn't have any psychology. So I've done a lot of work in physical health settings in the past. There's such a thirst for what you bring. There is such a huge enthusiasm for that difference in your expertise and it's often really welcomed. So that's my sense about it but I am a bit prone to wearing rose tinted spectacles, so Adrian I don't know if you want to slightly shift the perspective?

Adrian Neal (: 01:03:42

So, yeah, don't disagree with anything that Benna said. I guess for me, it's a bit like, you know, if you're a psychologist working in an area where there’s not many psychologists, that's a privilege, but it's also an interesting area. As Benna was talking, I was kind of thinking, do I see myself as a clin psych? I'm not sure I do. You know, I've been mostly influenced by organisational psychology for the last 10 years in terms of literature and evidence. But I guess I tend to, yeah, so I tend to introduce myself as a consultant psychologist because the consultant brand carries weight as a symbol in the NHS. So that's intentional. I guess I also talk about myself as being the professional psychologist involved. And that's, I guess, my way of saying I'm the one who's qualified in here, in the space. And it's, there is a personal bugbear in many ways, because I guess, we're proliferated with pop psychology, aren't we? And we know a lot of our colleagues in the workforce sector are very passionate and keen to understand psychology. Brilliant. But the people that can promote themselves in that space are not always credible, but social media is great at making yourself look great. So I tend to use those kind of monikers as, to authorise me to speak in that sphere. Yeah. I guess also using the doctor title is useful again, like consultant, it carries weight in the medical areas. It's less useful in some areas, but I think that helps a system that responds to symbols and is hierarchical. So that can be useful. So yeah, just something.

Paula Redmond (: 01:05:28

And Andrew, I wonder if you've got any observations of what that's been like to have this clinical psychology or psychology kind of involved in this work?

Andrew Cooper (: 01:05:36

So I expected more kickback from HR. I expected there to be a reluctance to engage with this. Actually, for the main part, colleagues have welcomed it. And I think that was a sense of their own discomfort with it. You know, those conversations that we have at our training. A senior colleague said to me quite recently, Andrew, if you've been in HR for any length of time, there will be things that you feel uncomfortable about. So what the psychology perspective I think has brought, I think has brought a number of things. First of all, that understanding of impact, impacts to the individual and impact as Adrian said on an organisational basis to the system. I think the discipline is much more curious around why do things go wrong? How can we do it differently? Has been incredibly helpful from that perspective. And certainly the way that we position this work and actually disciplinary processes need much more of the multidisciplinary approach to them that whereas they perhaps historically have sat within HR, actually, if we are going to take a more recent trauma informed approach, then we need HR managers, trade union representative, wellbeing, occupational health in the mix to be shaping the approach and making better decisions than we might have done in the past.

Paula Redmond (: 01:07:10

It's really exciting to hear that you're doing this work because I guess that, I mean even just from a personal perspective, that people are attending to this and it's having an impact is really good. So what's next for this work? What's coming up?

Andrew Cooper (: 01:07:24

Well, we've been working within healthcare for the last two or three years, really seeking to understand the impact, looking at what interventions that we can develop and seeking to bring change, working with HR colleagues in this space. What's been interesting, we've increasingly engaged with other sectors and we've talked to them about this work and generally the common response is we don't have it right here either so that actually this isn't an issue just for healthcare. I think if we think about that approach to understanding disciplinary policy and not really understanding what a good process looks like across these sectors. So we've been working, we've started to work with local authorities, we've got other sectors coming on board equally interested and then delighted that the three of us have been involved in a book that's coming out later this year. The book’s called ‘Under Investigation, Transforming Disciplinary Practice in the Workplace’. And really the aim is to continue a conversation with HR colleagues, managers, organisations across sectors to see whether some of the journey we've been on, and certainly the journey others have been on in terms of making improvements in this place can be scaled up and make even greater impact, not only for individuals going through these processes, but also their organisations as well, so that it's a better experience for work, but also organisations can deliver better outcomes as a result too.

Paula Redmond (: 01:09:01

Well thank you so much guys, that's been fantastic.

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