Toxic workplace culture highlighted at maternity care inquiry
Maternity units are complex, high pressure environments and no two trusts are the same. But the rise in blame culture, bullying and the fear of being struck-off were just some issues highlighted in this week’s Health and Social Care Committee inquiry into NHS maternity care.
Toxic traits within the workplace are preventing improvements to safety and poor obstetrics care from happening. Regulators have called for a less adversarial approach and resources that enable an ‘upstream’ practice that anticipates mistakes and prevents further investigations.
Fear of being struck off
Every employee is at risk of making mistakes in whatever industry they work in. But within medicine, and especially maternity, the price of a human error is a human life. Sadly, mistakes do happen and sometimes the outcome is tragic.
The inquiry heard from the GMC’s Charlie Massey how there is a degree of fear within obstetrics that any mistakes or errors made will automatically result in serious sanctions such as being struck off the medical register. Yet only five out of 257 cases taken to a tribunal were from clinical failures alone. Sexual misconduct, criminality and substance abuse were more likely causes.
Stripping someone of their medical licence isn’t the only option for retribution. Remediation, remorse and insight can help prevent future failings. Key decision makers should be trained in human factors techniques and hold accountability as a principle of good working practice.
This culture of blame and not taking responsibility for individual actions only leads to repeated tragedies and the system of failures which has become endemic in recent years within some NHS trusts’ maternity units. Staff should know the difference between human – and forgivable – errors, and those gross errors that lead to unacceptable practices such as dishonesty and cover-ups.
Bullying rates in maternity double the NHS average
Mr Massey also discussed how OB/GYN has the highest bullying, burn-out and drop-out rates of all NHS trainees. Around 14 percent of maternity trainees have experienced bullying, compared to an average of six percent across the NHS.
Leadership challenges contribute to these figures, particularly the tribalism that sometimes occurs between doctors and nurses. A well-led, multi-disciplinary team will feel empowered to speak up if they witness bullying or wrong practice. Witnessing bullying has a profound and chilling impact on staff and this undermining behaviour, particularly of trainees and newly qualified midwives, should not be tolerated.
Chief executive of the NMC, Angela Sutcliffe, spoke about how many aspects of the regulations staff are governed by creates an adversarial culture. Language used, particularly in medical negligence compensation claims, such as ‘allegations’ creates a defensive reaction from staff and prevents meaningful conversations from taking place. Less combative techniques would benefit everyone – from staff not feeling like they are on trial, to families not being made to constantly repeat and relive the worst times of their lives.
In Sweden, for example, victims of birth injuries don’t have to prove clinical negligence occurred to claim compensation. It was argued that mirroring such practices and changing the laws and eligibility regarding such incidents could help build better, more constructive relationships and learning cultures.
Need for better training established to improve best practice
Together with the GMC, work is being done to address these issues including implementing new standards of expectations, training and practice. Education and guidance have important roles to play in getting staff to speak up and change the mindset of the organisation.
Angela Sutcliffe accepted the need for more funding and time for maternity staff to keep up to date with training. The government has pledged £9million to improve fetal heart monitoring training which is critical for staff to confidently know when things are going wrong during labour. She also emphasised the importance of multi-disciplinary training to ensure everyone works effectively together to give women the best possible care. From later this year, a new £500,000 leadership training scheme is being rolled out to facilitate greater collaborative working between nurses, doctors, midwives and obstetricians.
The NMC has established a public support service whereby they work with families affected by poor maternity care. Staff and panel members are being trained to respond better to such cases. Witnesses to vulnerable situations are also being given better support so they don’t feel under scrutiny. Through the Fitness to Practice hearings, the NMC also hopes to work closer with employers to educate staff around liability, with more accessible clinical advice.
Stress and pressure contributing to unsafe staffing levels
Safe staffing levels were also discussed during the inquiry. Demand for specialist staff has increased due to a rise in high-risk pregnancies from diabetes, substance abuse and FGM. And while the presence of consultants on maternity units has gone up in the last 20 years, safe staffing levels are still not being met.
Jo Mounfield, VP for workforce and professionalism at Royal College of Obstetricians and Gynaecologists, told the inquiry there currently aren’t enough newly qualified midwives or OB/GYN doctors to fill the gap of safe working numbers expected by Birthrate Plus and the NHS. Nine out of ten trainees said there were gaps in the rotas at every level.
Neonatal deaths have become stagnated over the last decade since inquiries and reforms began, with rates not moving much despite a decrease in stillbirths. Staff experiencing stress from heavy workloads are more likely to make mistakes. Too much pressure and no access to meaningful developments are reasons given when medical staff leave the register. Some midwives had also had to pay for their own training or attend during annual leave, which only exasperates their not feeling valued within the workplace.
To improve practices within maternity care, it is clear much needs to be done to avoid future scandals such as those at the Shrewsbury and Telford Hospitals Trust and East Kent Hospitals University Trust. This battleground attitude will not help reduce errors or save lives.