Bullying and Harassment in the Health Sector

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:

13. 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
14. 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
15. 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
16. 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.

1.1 Defining the problem

1.1.1 Workplace bullying

Definitions vary for workplace bullying. For the purposes of this audit, workplace bullying is defined as repeated and unreasonable behaviour directed towards a worker or a group of workers that creates a risk to health and safety.

Unreasonable behaviour refers to behaviour that a reasonable person, having considered the circumstances, would see as unreasonable and includes that which victimises, humiliates, intimidates or threatens.

Examples of bullying behaviour—whether intentional or unintentional—include:

• abusive, insulting or offensive language or comments
• unjustified criticism or complaints
• deliberately excluding someone from workplace activities
• withholding information that is vital for effective work performance
• setting unreasonable time lines or constantly changing deadlines
• setting tasks that are unreasonably below or beyond a person's skill level
• denying access to information, supervision, consultation or resources to the detriment of the worker
• spreading misinformation or malicious rumours
• changing work arrangements such as rosters and leave to deliberately inconvenience a particular worker or workers.

What is not workplace bullying

Reasonable management action taken in a reasonable way is not workplace bullying—such as the allocation of work and giving fair and reasonable feedback. A single incident of unreasonable behaviour is not on its own workplace bullying, however, it may have the potential to escalate and should not be ignored. Workplace conflict is not, on its own, workplace bullying, as not all conflicts have negative health effects. However, conflict may escalate to the point where it becomes workplace bullying.

1.1.2 Harassment

Harassment occurs when a person or a group is treated less favourably than another person or group because of a particular characteristic—such as ethnic origin, gender, age, disability or religion. Harassment includes telling insulting jokes about particular racial groups, sending explicit or sexually suggestive emails or even asking intrusive questions about someone's personal life. Unlike bullying, harassment may be a single incident and is based on a characteristic of the affected person.

1.1.3 Bullying and harassment as part of a continuum

Bullying exists on a continuum of inappropriate workplace behaviour. Evidence highlights that workplace conflict or minor inappropriate behaviours can easily escalate into behaviour that is bullying or harassment. Early intervention is needed to prevent this.

In addition, minor inappropriate or unprofessional behaviours can cause harm and distress and pose a risk to health and safety, and therefore need to be appropriately resolved. This audit focuses on the continuum of inappropriate workplace behaviour which includes bullying and harassment.

1.2 Trends in bullying and harassment

The prevalence of bullying and harassment in the health sector is not conclusively known. However, research suggests that there are high levels of perceived bullying and harassment within health sector agencies (25 per cent) and in the experience of surgeons (38.7 per cent) and nursing professionals (40 per cent). Figures 1A, 1B and 1C summarise research findings.

Figure 1A

Prevalence of workplace bullying as reported by the Victorian public health sector and the Victorian public sector

Source: Victorian Public Sector Commission, 2013.

Figure 1B

Prevalence of bullying and harassment reported by surgeons and trainees in Australia and New Zealand

(a) n = sample size.

Note: Trainees are those undergoing surgical education and training. Elsewhere, this group is referred to as junior doctors, along with doctors at any stage of training.

Source: Royal Australasian College of Surgeons Prevalence Study, 2015.

Figure 1C

Prevalence of workplace bullying reported by nursing professionals

(a) n = sample size.

Source: Monash University, Leading indicators of occupational health and safety: A report on a survey of Australian Nursing and Midwifery Federation (Victoria branch) members,2015.

1.3 Impact of bullying and harassment

Bullying and harassment has been shown to have significant negative outcomes for individuals and organisations. It can cause serious physical and psychological harm to both those experiencing it and to witnesses, including:

• distress, anxiety, panic attacks or sleep disturbance
• physical illness, for example muscular tension, headaches, digestive problems
• reduced work performance
• loss of self-esteem and feelings of isolation
• reduced job satisfaction and commitment, with those experiencing bullying more likely to have negative views on their manager, work group and organisation, and more likely to report thinking of leaving
• deteriorating relationships with colleagues, friends and family
• depression
• thoughts of suicide
• financial impacts of time off work, medical costs, loss of job promotion opportunities and risk of permanent disability.

The impact of bullying and harassment on health service organisations and the sector are significant and include:

• high staff turnover and associated recruitment and training costs
• reduced productivity through low morale and motivation, negative workplace culture and higher rates of sick leave and disengagement
• increased absenteeism
• negative impact on patient safety outcomes
• disruption to work and high management impact through the time involved in responding to and investigating allegations of bullying and harassment
• difficulties in recruiting and retaining staff
• potential for significant legal costs
• reputational risk.

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

1.4 Preventing and responding to inappropriate behaviour including bullying and harassment

The risk of inappropriate behaviour and workplace bullying, can be eliminated or minimised by taking steps to prevent it from occurring long before it becomes a risk to health and safety, and by responding quickly when it does occur. Fundamental to this is the need to create a positive workplace where everyone treats each other with respect.

Adopting a risk management approach, shown in Figure 1D, enables agencies to:

• identify the potential for workplace bullying through data and identifying organisational risk factors
• implement control measures to prevent, minimise and respond to these risks, such as building a positive, respectful culture with good management practices and systems of work
• monitor and review the effectiveness of these control measures.

Figure 1D

Risk management approach to bullying and harassment

Source: Adapted from Safe Work Australia, Guide for Preventing and Responding to Workplace Bullying, 2013.

1.5 Legislation

A range of legislation creates obligations on parties to effectively manage the risk of workplace bullying and harassment:

• The Occupational Health and Safety Act 2004 is aimed at securing the health, safety and welfare of employees and others at work and eliminating risks at the source. An employer must, so far as is reasonably practicable, provide and maintain a working environment that is safe and without risks to health. This includes identifying and eliminating, controlling or reducing risks to health and safety. An employee must also take reasonable care for his or her own health and safety, and have regard for the health and safety of others.
• The Fair Work Act 2009 covers national workplace relations laws, National Employment Standards, protection against unfair treatment and discrimination, and grievance handling mechanisms. Under the Act, a worker who reasonably believes that he or she has been bullied at work can apply to the Fair WorkCommission for an order to stop the bullying.
• The Crimes Act 1958 makes it a crime to use, perform or direct abusive and offensive words or acts towards or in the presence of a victim, or to act in way that could reasonably be expected to cause physical or mental harm to a victim, including self-harm.
• The Public Administration Act 2004 articulates public sector values and the Public Sector Employment Principles.
• The Health Services Act 1988 establishes the functions of the board of a public health service. These functions include monitoring the performance of the health service to ensure that effective and accountable risk management systems are in place and adopting a Code of Conduct for staff of the public health service.
• The Equal Opportunity Act 2010 has provisions relating to equal opportunity and protection against discrimination, sexual harassment and victimisation. It has a strong focus on the prevention of sexual harassment.

1.6 Roles and responsibilities

Health services and Ambulance Victoria

Health services are the largest employer group in the public sector. Health service boards, which often manage more than one hospital, are responsible for steering the entity on behalf of the Minister for Health in accordance with government policy. This governance role involves strategic leadership of the organisation, monitoring performance against agreed objectives and ensuring accountability and compliance. Health service boards are responsible for the occupational health and safety of their employees.

Ambulance Victoria employs more than 3 000 employees and almost 1 000 volunteers. Its board has similar functions to that of health services and is also responsible for the occupational health and safety of its employees.

The chief executive officer of both health services and Ambulance Victoria is appointed by and reports to the board, and is responsible for the day-to-day management of their agency.

Department of Health & Human Services

The Department of Health & Human Services (DHHS) has a devolved governance model and is responsible for setting strategic priorities, implementing policy, monitoring the performance of health services and providing overall system-wide guidance and funding. Devolved governance allows health services to make local decisions to meet local needs. As manager of the Victorian health system, DHHS is responsible for making sure health service boards are maintaining a duty of care and commitment to providing all employees with a healthy and safe workplace.

Victorian Public Sector Commission

Consistent with its objective of maintaining and advocating for public sector professionalism and integrity, the role of the Victorian Public Sector Commission (VPSC) is to strengthen the efficiency, effectiveness and capability of the public sector. It is responsible for issuing and applying codes of conduct and standards, and monitoring and reporting to the public sector on compliance with these standards, including the public sector values and employment principles. To fulfil these obligations, VPSC administers the People Matter survey. Health services participate in the survey on a rotating basis—half one year and half the following year.

WorkSafe Victoria

WorkSafe Victoria is the regulator of Victoria's workplace safety system. Its role includes monitoring and enforcing compliance with the Occupational Health and Safety Act 2004 and assisting in preventing workplace injuries. It also provides information and education activities.

Australasian Royal College of Surgeons

The Australasian Royal College of Surgeons (RACS) provides surgical standards, professionalism and surgical education in Australia and New Zealand. In April 2015, RACS established an Expert Advisory Group to undertake research into the extent of discrimination, bullying and sexual harassment in the practice of surgery in Australia and New Zealand. Research undertaken included a prevalence survey, organisational survey and in-depth study into the personal experiences of bullying, harassment and discrimination.

1.7 Audit objective and scope

The objective of this audit was to determine whether public health services are effectively managing the risk of bullying and harassment in the workplace.

To achieve this objective, the audit assessed whether audited agencies:

• understand the causes, prevalence and impact of bullying and harassment
• implement effective controls to identify and manage the incidence of workplace bullying and harassment
• respond effectively to and address complaints and incidents of bullying and harassment
• monitor and assess the performance of health services in effectively reducing the drivers of bullying and harassment
• collaborate and support sector-wide initiatives to promote positive workforce behaviour.

This audit included Ambulance Victoria and four public health services. The health services comprised 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 the People Matter survey and stakeholder consultations.

The audit also included DHHS, WorkSafe Victoria and VPSC.

1.8 Audit method and cost

During the audit, we undertook site visits to the four audited health services and Ambulance Victoria, conducting interviews and focus groups:

• 14 individual and group interviews with executives and senior managers
• six focus groups involving 53 line or team managers
• seven focus groups involving 52 clinical and support staff and paramedics
• fourfocus groups with 21 junior doctor and paramedics.

We also reviewed audited agencies' systems and documents, including:

• relevant internal management and information systems and processes
• policies and procedures
• data and surveys
• workers' compensation claims
• investigation material.

We conducted an online public submissions process, through which we received 82 submissions from the public regarding their experiences of bullying and harassment in the health sector. While these submissions are subjective in nature, an analysis of recurring themes indicates common reported experiences of bullying and health services' response to bullying.

We also conducted a forum with human resources directors from 14 health services, which covered issues related to definitions, response, impact and prevention.

The audit was conducted in accordance with section 15 of the Audit Act 1994 and the Australian Auditing and Assurance Standards.

Pursuant to section 20(3) of the Audit Act 1994, unless otherwise indicated, any persons named in this report are not the subject of adverse comment or opinion.

The total cost of the audit was $585 000.

1.9 Structure of the report

The report is structured as follows:

• Part 2 examines audited agencies' culture, governance and leadership as foundations for effectively managing the risk of bullying and harassment
• Part 3 examines audited agencies' effectiveness in minimising the risk through implementing effective preventative controls
• Part 4 examines the effectiveness of audited agencies' complaints response mechanisms
• Part 5 examines the role of sector-wide agencies—DHHS, WorkSafe and VPSC—in supporting the health sector's management of this risk.

2.1 Introduction

It is widely acknowledged that positive and respectful workplace culture and values are key to preventing and managing inappropriate behaviours, including bullying and harassment. A strong safety culture consistently places a high priority on worker safety. Leadership commitment and clear accountability are also needed to reduce the risk of bullying and harassment. Identifying the risk—by understanding the causes, prevalence and impact of bullying and harassment—and reporting to the leadership team is important so that they can respond effectively and assess whether controls are minimising the risk and, therefore, whether they are fulfilling their responsibilities as employers under occupational health and safety (OHS) legislation.

2.2 Conclusion

The leadership of audited health sector agencies do not place sufficient priority on reducing inappropriate behaviour including bullying and harassment. Poor accountability at multiple levels and leadership teams' poor understanding of the hazard—particularly the causes, prevalence and impact of bullying and harassment—undermine the workplace culture. Indicators include:

• insufficient priority and leadership commitment to reducing inappropriate behaviour including bullying and harassment
• failure to manage bullying and harassment through a risk management framework, despite it being a risk with serious consequences
• poor accountability for inappropriate behaviour, bullying and harassment, including at senior levels within health sector organisations
• pervasive fear and reluctance by staff to raise issues or make formal complaints because of the perceived repercussions of doing so.

There are some signs that audited agencies are attempting to change the culture within their organisations, to adopt one that does not accept workplace bullying and harassment. This is a long-term challenge which will require more sustained leadership focus and commitment than has currently been demonstrated.

2.3 Inadequate leadership commitment

The leadership—the board and executive of audited agencies—currently has inadequate governance and oversight of the risk posed by bullying and harassment. Although the leadership has a duty of care to its employees under OHS legislation, bullying and harassment is not given the level of priority the seriousness of the risk demands.

In addition, a failure to demonstrate consistent accountability for inappropriate behaviour, bullying and harassment, including at senior levels, was reported within all audited agencies, including a consistent failure to hold senior staff to account for inappropriate behaviours.

2.3.1 Insufficient priority

Health sector agencies have largely failed to identify bullying and harassment as a risk or to manage it effectively. While each audited agency describes bullying as a 'risk to health and safety', no audited agency applies standard risk management principles to its management of bullying and harassment.

This is despite the fact that the definition of bullying and harassment—nationally and by all state jurisdictions—emphasises the need to manage it through a risk management framework.

Using a risk management framework would allow agencies to identify and assess the potential for workplace bullying, to implement control measures to prevent, minimise and respond to these risks, and to monitor and review the effectiveness of these control measures.

The failure to recognise and address bullying and harassment through a risk management framework means that such behaviour is managed at the level of the individual on a case-by-case basis, with little focus on prevention and continuous improvement at an organisational level. This is all the more important given that changing culture is a long-term challenge.

By analysing the extensive data it collects on the public sector, the Victorian Public Sector Commission (VPSC) found that 'when behaviour is individualised, it has the potential to hide the underlying organisational factors driving the behaviour'. The 2012 Australian Parliamentary inquiry into workplace bullying found that only responding to bullying and harassment at the level of the individual can also lead to under-reporting and mask the extent of bullying and harassment, as:

• bystanders are less likely to intervene or raise concerns about situations that are framed as individual, inter-personal conflicts
• staff are less likely to have the confidence to report issues.

2.3.2 Failure to identify and understand the hazard

Because the reporting of bullying and harassment to leadership at the audited agencies is absent, inadequate, unreliable or inconsistent, it is difficult for leadership teams to discharge their duty of care to employees and manage bullying and harassment as an organisational risk—even when it is considered a priority. Failing to collect good data means that the leadership teams cannot respond effectively or assess whether controls are minimising the risk of bullying and harassment. Information reported to the boards of the audited agencies did not identify or quantify the causes, prevalence and impact of bullying and harassment. Instead, the information was very poor:

• Three audited agencies do not report bullying and harassment complaints at all to their leadership teams.
• The remaining two audited agencies report complaints to leadership, but these are aggregated with other human resources issues so it is not possible to understand the prevalence of bullying and harassment. For instance, one agency's report was limited to the total number of Fair Work 'arbitrations', 'conciliations', 'investigations and reviews' and 'concerns and inquiries' for that month, any of which might or might not relate to bullying and harassment behaviour.
• In addition, other key information that should inform an appropriate response is missing:
• trends over time in bullying and harassment complaints
• clinical and operational areas with increased numbers of complaints
• outcomes of complaints.
• Broader organisational indicators, such as staff turnover, unplanned leave and absenteeism, are not integrated. Understanding rates of these indicators and richer data on the complaints process can collectively provide a better understanding of the prevalence and impact of bullying and harassment across an organisation.

One audited agency has recently begun reporting to the executive the 'number and outcomes of substantiated bullying, harassment and intimidation complaints', which is an improvement. Three audited agencies have also prepared one-off discussion papers on bullying and harassment recently, which combine multiple types of data to identify trends. One agency prepared this discussion paper after recognising that bullying and harassment issues were negatively affecting its reputation and ability to attract and recruit high-calibre clinical staff. This is a good example of how leadership should monitor these factors and interpret what the information means for the agency.

Despite inadequate information, the leadership of the audited agencies have not requested better or more information, or deeper analysis that could improve their understanding of bullying and harassment across their organisations.

Representatives of three boards acknowledged that they:

• are unclear on what information they should be asking for and uncertain how to monitor workplace culture, bullying and harassment given the information they receive
• are unclear how to respond appropriately, given the challenges bullying and harassment pose
• need better training and support to fulfil this function, including knowing the right questions to ask, indicators of concern and best-practice responses for different types of issues
• need stronger leadership from the Department of Health & Human Services (DHHS), particularly in providing improved training and support.

They also reported a desire for DHHS to develop indicators related to workplace culture.

Board representatives at the other two audited agencies were not aware of the inadequacy of the information they received and, therefore, of their failure to adequately monitor the issue. This was despite acknowledging that they did not know the causes, prevalence and impacts of bullying and harassment within their respective organisations. This only emphasises the need to develop board capability to understand and interpret relevant data and information, so that they all fully understand the risks they are responsible for.

Limited attention to improving inadequate information

Audited agencies have given limited attention to improving poor and unreliable information and building a stronger understanding about the causes, prevalence, impact and trends of bullying and harassment across their organisations. However, this is changing—two agencies are improving their respective OHS reporting systems, and three agencies are currently undertaking additional targeted surveys to determine the extent of bullying and harassment. It will be important for this information to be analysed and presented to the board for consideration.

While new surveys can be valuable, the whole health sector (including the audited agencies) has been slow to use the information that is freely available through VPSC's People Matter survey. The survey provides the option to the health sector of including questions on the work unit and role level, of each respondent. However, as of 2015, only 25 per cent of the Victorian health sector included these questions which enable agencies to identify where workplace bullying is reportedly occurring.

2.3.3 Poor accountability

Executive and senior management

Line managers and staff across all audited agencies identified poor role modelling in the behaviour of the executive and senior managers. Ten of 17 focus groups identified this issue, including five of the six line manager groups and four of the seven staff groups. These focus groups also identified a consistent failure to hold senior staff to account for inappropriate behaviours and described a 'double standard' whereby some staff are 'untouchable' despite their consistently inappropriate behaviour being common knowledge. Both line managers and staff stated that it was important to establish consistent expectations across the organisation—however, this becomes impossible if senior management model poor behaviour.

The Parliamentary inquiry and research shows that leaders and managers play a pivotal role in creating the culture of the workplace through what they say and do. Leaders need to model appropriate behaviour and deal with inappropriate behaviour when they become aware of it.

This is in stark contrast to what is reported to be the situation in the audited agencies. The majority of the focus groups (14 of 17) reported that there is no point reporting instances of inappropriate behaviour, including bullying and harassment, as nothing will be done. These views were held equally strongly across roles—the issue was reported in all junior doctor and paramedic focus groups, in the majority of line manager groups, and in the majority of staff groups, across all audited agencies. Along with the fear of repercussions, this belief makes staff reluctant to report incidents of inappropriate behaviour early, or at all. This finding is supported by analysis of the 82 public submissions received during this audit:

• 40 per cent of all submissions (32 responses) stated that those with poor behaviour were not held to account
• 23 per cent of all submissions (19 responses) identified issues with poor adherence to policies and procedures.

Clinicians

Line managers, staff and junior doctors across all audited health services reported that health services fail to hold clinicians to account for poor behaviour. This view was expressed by 10 of the 17 focus groups, or almost 60 per cent, including all six of the line manager groups, four of the seven staff groups, and two of the four junior doctor groups.

Group interviews with the board, executive and senior clinicians at two audited agencies agreed with the assessment that poor behaviour by clinicians is common. One of the executives, in an interview with VAGO, commented: 'Doctors are immune. This cannot go on—we cannot have different rules for different people, no matter how important they are.'

Findings from the focus groups are supported by an extensive 2015 national survey by the Royal Australasian College of Surgeons (RACS). In this survey, almost half (1 516) of all surgeons who responded to the survey reported experiencing discrimination, bullying, sexual harassment or harassment, as shown in Figure 2A.

Figure 2A

Experience of bullying and harassment—2015 Royal Australasian College of Surgeons survey

(a) n = sample size.

Source: Victorian Auditor-General's Office using data from the RACS survey, 2015.

In addition, over half of surgeons (57 per cent, or 569 surgeons) who sought to address the behaviour were not satisfied with how the issues they raised had been resolved. Figure 2B details the low proportion of surgeons and trainees who felt that their issues of discrimination, bullying and sexual harassment were dealt with effectively.

Figure 2B

Ineffective response to clinicians' poor behaviour— 2015 Royal Australasian College of Surgeons survey

(a) n = sample size

Source: RACS survey, 2015.

In interviews, the executives at three of the audited health services acknowledged their limited effectiveness in tackling the poor behaviour of senior clinicians. They reported that there were considerable barriers faced in addressing inappropriate behaviour including bullying and harassment. Barriers include the high cost incurred in legal fees, the time it takes to address complaints, the lack of clarity about accountability and the poor information exchange across speciality colleges, health services and universities.

2.4 Under-reporting of bullying and harassment

Focus groups of staff at different levels and the public submissions received during this audit overwhelmingly indicate high under-reporting of inappropriate behaviour including bullying and harassment. Half the senior managers interviewed also acknowledged extensive under-reporting. Significant under-reporting means that even if the reliability of the available data improved, it would still not provide a complete picture of the extent of the problem, including the true causes and prevalence of bullying and harassment across an organisation.

Our focus groups and public submissions identify consistent reasons for under‑reporting, including:

• belief that there is little point in reporting incidents, as inappropriate behaviour including bullying and harassment is not addressed
• distrust of human resources teams, who manage complaints of bullying and harassment
• fear of repercussions.

The RACS survey also found indications of under-reporting and reported reasons consistent with those above. The reasons for under-reporting, by data source, are shown in Figure 2C.

Figure 2C

Reasons for under-reporting of bullying and harassment

Source: Victorian Auditor-General's Office.

While there was a consistent unwillingness to report behaviours of concern, some staff identified that they would report issues if they related to the wellbeing of a colleague or junior doctor, or if they were affecting patient safety. Line managers in three of the six focus groups related experiences in which inappropriate behaviour including bullying and harassment undermined patient safety. Examples include being prevented from gaining access to patients to deliver treatment, being deliberately given insufficient information about a patient, making mistakes as a result of stress, and the dangers of fatigue as a result of unreasonable rostering decisions.

Focus groups comprised of junior doctors indicated a high degree of acceptance of bullying and harassment—such behaviour was explained as a 'training technique' that helped motivate them to work harder, or as unfortunate but an inevitable rite of passage and part of the 'old-school way'. Junior doctors stated that they were reluctant to report inappropriate behaviour including bullying and harassment for fear of repercussions, because of the entrenched acceptance of poor behaviour and because they did not know how to raise the issues. Despite this, junior doctors at the three health services that offer clinical training programs all identified negative impacts of this approach, including damage to confidence, risks to patient safety, permanent damage to reputation, dropping out of the program and even suicide.

The widespread sense of fear experienced as a result of reporting issues is highlighted in the direct quotes from public submissions included in Figure 2D.

Figure 2D

Quotes regarding fear of reporting bullying and harassment

Source: Victorian Auditor-General's Office.

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.

3.1 Introduction

Under the Occupational Health and Safety Act 2004, employers are obligated to eliminate or, if that is not possible, minimise so far as is reasonably practicable risks to the health and safety of their employees. The risk of workplace bullying and harassment (which includes all inappropriate behaviour) can be eliminated or minimised with a range of controls, such as positive culture initiatives, policies, training and education. A risk management approach involves:

• 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 building a positive, respectful culture and developing good management practices and systems of work
• monitoring and reviewing the effectiveness of these control measures.

This part assesses these preventative controls.

3.2 Conclusion

The audited agencies cannot demonstrate that they have effective preventative controls in place to reduce workplace bullying and harassment. Key controls that would effectively reduce this risk to employee health and safety are either inadequately implemented, missing or poorly coordinated.

3.3 Policies and procedures

Policies and procedures are not acting as an effective control to reduce the risk of bullying and harassment in the audited agencies. Although each of the audited agencies has policies and procedures in place, some are unclear, have significant gaps or are not evaluated. In addition, our focus groups and analysis of public submissions indicate that staff do not:

• fully understand the policies and procedures
• believe the policies and procedures are effectively implemented
• comply with policies and procedures, despite being obliged to do so.

Policies and procedures should establish clear standards and expectations of appropriate behaviour for all employees and clearly outline staff responsibilities. They should also clearly detail procedures for responding to behaviours that do not meet these expectations. Policies and procedures should be comprehensive and ensure consistent and transparent practice, need to be known and understood, and should be complied with to ensure safe systems of work are being maintained.

3.3.1 Inadequate policies and procedures

Unclear and overlapping policies and procedures

Although all audited agencies have policies and procedures relating to bullying and harassment in place, they are complex and overlapping and, at times, they are in conflict with one another. This is because audited agencies do not provide an overarching policy framework to guide and integrate their organisational approach to managing inappropriate behaviour including bullying and harassment.

An overarching policy framework should emphasise prevention and the value of building positive workplace relationships and culture. A policy framework forms an important link between setting expectations of professional behaviour through code of conduct policies—which have recently been introduced by four of the audited agencies—and the multiple procedures in place for dealing with both early intervention of issues raised informally and management of formal complaints and grievances about bullying and harassment. The current policies and procedures make it difficult for staff to understand the process and are ambiguous as to what response is required and when process steps should be undertaken:

• Conflicting policies and procedures—one audited agency has five complaints policies, each providing different guidance.
• Unclear rules and guidance for investigations—investigations are a key part of resolving a formal bullying and harassment complaint, yet guidance for the complainant and those managing the investigation is unclear. Four audited agencies did not indicate the threshold at which an investigation is required, or the circumstances under which an investigation should be undertaken by an external party, while one audited agency did not provide any investigation procedure whatsoever.
• Inadequate response options for substantiated complaints—one audited agency did not define the possible outcomes of the complaints process, such as disciplinary action, training or termination. No audited agency identified the potential for organisational responses or improvements as a result of bullying and harassment complaints. This highlights the tendency to deal with complaints individually rather than treating bullying and harassment as an organisational OHS risk.
• Inadequate response options for unsubstantiated complaints—no audited agency identified how it would respond to unsubstantiated complaints, whether at an organisational or individual level. This is a clear weakness—even if a complaint is unsubstantiated, there may be a valid issue to be resolved between the people involved or within the team.

Gaps in policies and procedures

There are also clear shortcomings in the audited agencies' policies and procedures related to bullying and harassment. Gaps include:

• No or limited information detailing the investigation process—three audited agencies had no information on the investigation process, such as the steps to undertaking an investigation, when it is appropriate to investigate, who should undertake investigations, and that options other than a line manager are available to ensure impartiality.
• Avenues of support available to staff—three audited agencies failed to identify external agencies that are available to support employees, such as WorkSafe Victoria, FairWork Australia and the Victorian Equal Opportunity and Human Rights Commission. This is significant because the Victorian Public Sector Commission (VPSC) People Matters Survey indicates that the health sector has the highest incidences of reported bullying in the public sector.
• Required complaints documentation not specified—only one audited agency committed to documenting and recording all stages in the process once a formal complaint was made. This lack of transparency undermines the integrity of the whole process.

Insufficient review of policies and procedures

Only two audited agencies had undertaken any review of the effectiveness of their policies or processes in the previous three years. In both cases, the reviews only considered the effectiveness of the investigation process.

3.3.2 Poor understanding of and compliance with policies and procedures

Staff from all levels across all audited agencies report poor understanding of bullying and harassment policies and procedures and noncompliance, as shown in Figure 3A.

Figure 3A

Poor knowledge, understanding of and compliance with policies and procedures

Source: Victorian Auditor-General's Office.

In three of the audited agencies, senior managers report that clinicians also routinely do not conform to the behaviour expected of them under the health service's policies. Additionally, clinicians including junior doctors rarely raise issues through health services' processes. This is important because clinicians, as leaders in the health sector, play an important role in establishing norms of behaviour. Further, it also indicates the high risk that junior doctors face through the inequality of power that exists between them and supervising clinicians, particularly in relation to performance grading and career progression.

The Royal Australasian College of Surgeons' (RACS) Confidential Draft Research Report confirmed entrenched barriers that prevent clinicians from being held to account. Quotes from respondents include:

'Surgeons are outside of the HR jurisdiction of the hospital administration and are accountable to no one for their behaviour …'

'[The] … reluctance to get involved or to investigate complaints of senior surgeons, and desire to retain hospital personnel takes precedence over the need to address inappropriate behaviour. A recurrent sub-theme is a failure to act, a failure to respond or a response that's ineffectual.'

3.4 Training and education

Training and education can help to reduce the risk of bullying and harassment, but are ineffective at the audited agencies. While some training is available, the audit found that it is inadequate, not mandatory and not evaluated for effectiveness.

Appropriate training and education ensures that workers, including managers and supervisors, understand their responsibilities and have the appropriate skills to take effective action when needed. Managers and supervisors, who are in the front line in relation to effective response and prevention, require the necessary skills to develop positive workplace cultures and good management practices.

3.4.1 Inadequate bullying and harassment awareness training

Bullying and harassment awareness training at the audited agencies is inadequate to build sufficient understanding of the causes and impact of this OHS risk. As shown in Figure 3B, training at some audited agencies is limited to short online modules that are not supplemented by other delivery modes. The training is mainly optional rather than being mandatory for all staff. At some agencies, relevant training has only recently been introduced.

Figure 3B

Bullying and harassment awareness training for staff

Source: Victorian Auditor-General's Office.

One of the audited agencies supplements its training with an online coaching tool that supports staff to develop strategies for managing conflict in the workplace.

None of the audited agencies evaluate the effectiveness of the training offered, but four of the agencies collect feedback from participants.

While the introduction of bullying and harassment awareness training is a positive step, six of seven focus groups with line managers identified that online delivery of this training did not provide sufficient information or adequately engage participants to build their understanding and capability of such a complex issue.

Insufficient training for managers

Training for managers in preventing and responding to inappropriate behaviour including bullying and harassment is inconsistent and insufficient. This means that those responsible for intervening early are not adequately trained to do so. Managers play an important role in establishing positive and respectful workplace cultures and addressing issues. It is important that they respond effectively to whatever issues are brought to them, however minor. This is a key control in reducing the risk of inappropriate behaviour including bullying and harassment. Figure 3C outlines the training available for managers across the audited agencies.

Figure 3C

Training, support and resources for managers in preventing and responding to inappropriate behaviour including bullying and harassment

Source: Victorian Auditor-General's Office.

One of the audited agencies supplements its training to managers with an online management coaching service that supports managers to effectively address issues brought to them. This is also supported by online guidance and management information cards.

None of the audited agencies evaluate the effectiveness of the management training they offer, though four of the agencies collect feedback from participants.

While two audited agencies have extensive training in good management skills, this training is not mandatory. Line managers at the audited agencies report that training can be difficult to access due to time constraints or limited awareness and availability. Only one audited agency provides training for managers on how to respond to bullying and harassment issues reported to them informally by staff, however, this was a one-off initiative.

The inadequacy of training at the audited agencies is supported by the results from the focus groups of staff and the RACS survey—detailed in Figure 3D. Consistent themes include lack of access to training, recognition of the need for more training and poor capability of line and middle managers (including clinicians) in effectively preventing and responding to inappropriate behaviour including bullying and harassment.

Figure 3D

Inadequate training

Source: Victorian Auditor-General's Office.

The capability of line managers to deal with inappropriate behaviour was also raised as a concern by human resources staff and senior managers in interviews.

3.5 Building positive and respectful workplace culture

Building positive and respectful workplace cultures is a key control for preventing inappropriate behaviour including bullying and harassment. Positive culture and respectful relationships require clear standards about expected behaviour, mechanisms to reward appropriate behaviour, and effective reporting and response procedures to address inappropriate behaviour including bullying and harassment.

The 2012 VPSC report Exploring workplace behaviours: from bullying to respect reported research that identified the importance of workplace culture and context for interpreting behaviour. A key finding was that the levels of trust in the organisation and relationships inform how behaviour is interpreted—the report states, 'employees are more likely to perceive that bullying is occurring where there are low levels of trust in their relationship with the person engaging in the behaviour and in the organisation itself.' This highlights the importance of:

• encouraging respectful behaviour and discouraging disrespectful behaviour
• treating perceptions of bullying—as observed in the People Matter survey—as a useful warning indicator
• building employee trust in relationships and the organisation by modelling the values required and emphasising the importance of the 'how' as well as the 'what' in performance management systems.

In acknowledgement of the important role of culture in this process, four audited agencies have introduced policies, undertaken workshops and conducted training sessions to promote positive workplace values and emphasise appropriate workplace behaviours.

One audited agency has started a cultural change journey that they state will be a five‑year process. The first step was identifying and understanding the problem by gathering and comparing data. This highlighted that issues with bullying and harassment were affecting their reputation and preventing recruitment and retention of clinical staff. The second step has been to develop a response to this problem. The cultural change program is in the early stages of implementation. It demonstrates a risk management approach which aims to prevent inappropriate behaviour by embedding a positive culture of safety and accountability across the agency. One element of this is the Safety Culture Program, which introduces an organisation-wide framework and training program focused on promoting professional accountability in relation to patient and staff safety. The steps they have taken are outlined in Figure 3E.

Figure 3E

Case study: A cultural change program

Source: Victorian Auditor-General's Office.

Recommendations

That health sector agencies:

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.

4.1 Introduction

WorkSafe, the occupational health and safety regulator, emphasises two key controls for effectively responding to inappropriate behaviour including bullying and harassment:

• early intervention, which involves self-managing inappropriate behaviour or seeking line management support to resolve issues
• robust formal complaints processes.

4.2 Conclusion

No audited agency could demonstrate that either of the key controls—early intervention or the formal complaints process—are operating effectively. No assurance mechanisms were in place to ensure managers are responding to issues brought to them effectively, or at all. The effectiveness of the formal complaints process is undermined by:

• high levels of known under-reporting
• inadequate complaints management systems and practices, including inconsistent or absent record keeping and documentation.

4.3 Ineffective early intervention

Early intervention is widely acknowledged as preferable to undergoing a formal complaints process, as it prevents escalation and reduces the impact of the issue or incident. Despite this, no data, mechanism or 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—as a mechanism to better understand the size of the problem in their agencies.

However, the majority of focus groups with line managers, staff, and junior doctors and paramedics (12 of 17 focus groups) indicate a perception that early intervention is largely ineffective and, as a result, there is little trust in this process. This also highlights the inadequacy of human resources departments to support line managers to fulfil this necessary function. The focus groups expressed a number of concerns:

• Line managers may be sympathetic but do not take action or are ineffective—which sometimes results in escalation of the inappropriate behaviour, including counter allegations of bullying.
• For some participants, there is reluctance to go outside the ward or team, as this may highlight internal team problems.
• If the line manager was complicit in the inappropriate behaviour, it was not possible to raise the issue with another line manager because of a perception that 'all managers are friends'.
• There was little knowledge of independent avenues of support—this was particularly the case for junior doctors and paramedics.
• There is fear of the repercussions that may result from raising an issue, such as:
  • damage to an individual's reputation
  • unfavourable performance reviews
  • unreasonable rostering
  • transfer to another work site
  • non-renewal of contract.

These issues are particularly relevant for certain groups of staff—for instance, shift workers such as nursing staff and those working in an organisation with a devolved regional structure such as Ambulance Victoria.

Line manager focus groups reported that, at times, they were prevented from taking action when issues were raised with them because the person raising the issue requested confidentiality and that no action be taken. This is another indication of fear of potential repercussions. Line managers reporting this experience felt that they were bound to keep the person's confidence, but expressed frustration at being unable to act.

The capability of line managers to effectively respond early to inappropriate behaviour was reported as a significant issue across all audited agencies. Five of six focus groups with line managers reported that they did not feel confident to handle complaints about inappropriate behaviour including bullying and harassment brought to their attention. In addition, focus groups at all levels and interviews with senior managers stated that line managers were not equipped to effectively manage such behaviour. This belief was reported in:

• 11 interviews with senior management from the audited agencies (including board members, chief executive officers, executive team members, human resources managers and senior clinical staff )
• five of six focus groups with line managers
• five of seven focus groups with staff
• three of four focus groups with junior doctors and paramedics.

4.4 Inadequate management of formal complaints

No audited agency could demonstrate that it systematically responds effectively to formal bullying and harassment complaints. Significant inadequacies in the formal complaints process were identified. These inadequacies confirmed the negative perceptions of the complaints process reported by focus groups from all levels of the organisations, as detailed in Parts 2 and 3 of this report.

An in-depth review of 33 formal complaints files from four audited agencies found that there were extensive deficiencies at each step in the process, indicating that serious formal complaints of bullying and harassment are not receiving the priority or attention they demand. Documentation was generally poor or absent, meaning that it was impossible to understand trends related to bullying and harassment. It was clear that policy and procedures are consistently being breached. Shortcomings are detailed in Figure 4A and include:

• incomplete documentation and record keeping including missing witness statements, interview records, investigation reports, outcomes of formal complaints and documentation authorising staff termination
• key complaints file information not being logged into a system that would enable analysis, monitoring or identification of trends
• investigation practices that are inconsistent, incomplete and lacking any justification or transparency
• no effort to address the underlying organisational factors that may have contributed to the behaviour
• failure to communicate key information, such as the right of both parties to seek a review of the decision.

Figure 4A

Limitations of complaint management practices identified through review of complaints documentation

Source: Victorian Auditor-General's Office.

These inadequacies are consistent with the experiences reported by participants in the focus groups and the public submissions. Issues identified through this process included:

• lack of trust in the capability and authority of human resources departments to respond effectively to complaints
• lack of trust in the independence and impartiality of the process
• lack of trust in the transparency and confidentiality of the complaints process, including the adequacy of the investigation process
• inadequate timeliness of the response
• failure to provide opportunity to seek review or to have a right of reply
• lack of support for complainants and respondents during and after the process
• insufficient action and poor redress, including failure to notify the complainant of the response to formal complaints.
• Shortcomings with the formal complaints process are also consistent with key themes emerging from the Royal Australasian College of Surgeons (RACS) survey, as shown in Figure 4B.

Figure 4B

Summary of the inadequacies of the complaints process

Source: Victorian Auditor-General's Office and RACS survey (2015).

Interviews with senior management in four audited agencies confirmed a lack of trust in the capability and independence of human resources departments.

The Royal Australasian College of Surgeons Confidential Draft Research Report (RACS Report) identified a similar range of inadequacies in complaints management processes. Respondents expressed a sense of futility in initiating any complaints process with either hospital management or RACS and reported:

• lack of procedural fairness, transparency and confidentiality
• belief that complaints are ignored
• lack of clarity about the process
• dissatisfaction with the length of time taken
• perception that senior surgeons collude or, at best, fail to act.

In one audited agency, there was a total failure to provide any support to complainants throughout a protracted and known bullying situation. A small rural health service had no human resources officer, independent employer assistance or OHS representative during a period of entrenched and persistent bullying. The temporary human resources staff employed during this period broke the confidentiality of staff by relaying information to the senior manager who was alleged to be the main bully.

Recommendations

That health sector agencies:

1. record issues related to inappropriate behaviour resolved through early intervention
2. with staff feedback, develop strategies to address reporting barriers, and implement and monitor these strategies
3. establish and deliver a robust formal complaints process
4. 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.

5.1 Introduction

With bullying and harassment presenting as a persistent risk across the health sector, a systemic response may be more effective and efficient than responses at the level of individual agencies. Collaboration between key sector-wide agencies could drive improvements and provide detailed guidance and programs that support the development of a safety culture in health settings. Together, the Department of Health & Human Services (DHHS), as the health system manager, and WorkSafe, as the occupational health and safety (OHS) regulator, can draw on work by the Victorian Public Sector Commission (VPSC) to better influence health and safety for workers in the health sector.

5.2 Conclusion

The health sector has insufficient guidance and support to develop consistent better practice in managing the risk of bullying and harassment. There is poor collaboration between the key sector-wide agencies—DHHS, WorkSafe and VPSC—which is needed to tackle the pervasive challenge of inappropriate behaviour including bullying and harassment in the health sector. A limited exchange of valuable information and poor pooling of knowledge represents a missed opportunity to support health leadership—board and executive teams—in need of assistance to reduce this risk in their organisations.

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

5.3 Poor sector-wide collaboration

Collaboration remains poor between key sector-wide agencies that have a role in supporting the safety culture of the health sector. VAGO's 2013 report Occupational Health and Safety Risk in Public Hospitals found that collaboration between the former Department of Health and WorkSafe had been poor for a number of years. Although the boards of health services and Ambulance Victoria hold primary responsibility for providing a safe workplace, this audit has shown the need for greater guidance and support to reduce the risk of inappropriate behaviour including bullying and harassment across the health sector. Better sector-wide collaboration is also needed in relation to sharing existing and new data to benchmark, identify and support health sector agencies at risk of poor safety performance.

There have been a number of missed opportunities to date. For example, VPSC has undertaken significant research on bullying and harassment, such as the longstanding People Matter survey, and has prepared a range of guides related to bullying and harassment, building positive culture and better management practice. These documents provide rich information for management to use—however, management teams at audited agencies were not aware of this material. There is an opportunity and need for DHHS to:

• promote such information to the health service CEOs and board chairs at regular meetings or at appropriate events, to build knowledge of the importance of best practice approaches to addressing this risk
• work in partnership with WorkSafe and VPSCto develop more detailed best practice guidance for preventing and responding to bullying in the health sector, adapted from VPSC'sresources and underpinned by health-sector-specific analysis of data from the People Matter survey.

As a result of the 2013 VAGO audit, both DHHS and WorkSafe acknowledged the need for greater collaboration, particularly in sharing sector-wide OHS information and responding to emerging OHS risks. However, this has not occurred in relation to bullying and harassment across the health sector—for instance, DHHS and WorkSafe have not worked together to collectively build board capability to help them understand and respond to OHS risks, including bullying and harassment, despite implementing strategies aimed at building the governance capability of boards.

Additionally, WorkSafe does not share de-identified bullying and harassment claims and related complaints data with DHHS, the health system manager. This data could assist DHHS to identify emerging trends and individual health services with potentially poor safety cultures.

VPSC has only recently shared with DHHS limited health sector results from the People Matter survey, including those related to bullying and harassment. This is primarily to inform DHHS's monitoring of patient safety cultures within health services. This information sharing is belated given its importance to identifying health services at risk.

Further, DHHS and WorkSafe have not drawn on the extensive body of evidence and research that VPSC has undertaken on trends in bullying or building positive workplace cultures. Better collaboration between the VPSC, DHHS and WorkSafe could help identify the factors and indicators that assess the strength of a health service's governance, culture and leadership—for instance, VPSC has identified strong correlations between perceptions that the an organisation is not tolerant of bullying with indicators of positive culture and leadership.

5.4 Insufficient guidance and support

There is insufficient guidance and assistance to support the health sector to adopt an appropriate risk management approach to bullying and harassment. Guidance that is available is either fragmented or not sufficiently tailored to the health sector and the unique challenges a hospital environment can pose. Specifically:

• DHHS provides no guidance on managing workplace inappropriate behaviour or bullying and harassment
• WorkSafe'sguidance on workplace bullying and harassment does not provide sufficient detail to adequately inform health services.

WorkSafe's guidance is fragmented across different documents and does not reflect the knowledge base that WorkSafe has built through its role as the OHS regulator. It includes minimal instruction in some of the areas in which we identified significant inadequacies. For example, WorkSafe's guidance does not provide information on the use and importance of a risk management framework for managing bullying and harassment, nor does it outline the types of data that can be used to understand bullying and harassment. It provides limited focus on prevention, such as the importance of building strong, respectful workplace relationships and a positive culture.

VPSC provides sufficient guidance to health services through its People Matter survey results. It also provides extensive research and guidance material in relation to bullying, culture, management, capability, codes and standards for the public sector. However, awareness of these resources is low—they are under-utilised and not sufficiently tailored or accessible to health sector management. VPSC produces a number of resources that could provide valuable insight to the health sector:

• People Matter survey for monitoring employees' perceptions of experiencing or witnessing bullying. Conducted since 2008, the People Matter survey can be disaggregated by sector. According to the survey, the perception that an organisationdoes not tolerate bullying is associated with four key indicators:
  • avenues of redress
  • perceptions of senior leaders
  • perceptions of integrity and support provided by work group
  • perceptions that managers communicate well and are respectful in their treatment of employees.
• Tackling Bullying guide for responding to immediate incidents of reported or observed bullying. It supports response and prevention by providing guidance on how to accept a duty of care to take action, how to be a supportive manager, how to assess the workplace culture of your team and how to decide what action to take if someone experiences, witnesses or is accused of bullying.
• Developing Conflict Resilient Workplaces guide for better managing workplace disputes and developing more positive approaches to conflict in the workplace. This guide is designed to assist Victorian public sector leaders and managers to create a working environment in which conflict is managed well and not allowed to escalate. It suggests ways to build commitment to change, review current practice, identify areas for improvement, present options for change and evaluate success.
• Feedback Matters report provides guidance on the potential effects and benefits of giving informal and formal feedback. Those receiving informal feedback are less likely to report having experienced bullying.The provision of feedback, particularly negative feedback, is one of the most difficult areas for managers, which contributes to its association with allegations of bullying.
• Managing Poor Behaviour in the Workplace and Talking Performance guides provide guidance on improving processes for managing poor performance and building managers' skills in having conversations about performance with employees, which is seen as a necessary aspect of building a positive culture and preventing inappropriate behaviour and bullying and harassment.

5.5 Building board capability

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

DHHS supports improved board capability through the Building Board Capability framework, which it uses to deliver workshops and information sessions. However, board members are encouraged, but not required, to attend.

WorkSafe, as a result of the recommendations in our 2013 audit, has presented to health service boards on their accountability and required approach to managing OHS risks. This presentation does not mention bullying and harassment as an OHS risk, nor does it provide any guidance about prevention and response.

Both these mechanisms could be enhanced to provide greater guidance and information about boards' responsibilities in relation to bullying and harassment risk and other OHS risks.

The national research in Safe Work Australia's 2012 Australian Workplace Barometer, adopted by the Australian Public Service, identified organisational features that predict poor workplace cultures and increase the risk of bullying and harassment. These lead indicators include workplace demands, worker influence over their work and the leadership and management priority given to protecting workers' psychological health and wellbeing. Adoption of these indicators points to a shift toward risk prevention through identifying organisational causes. Indicators such as these could enable boards to better understand, monitor and predict the risk of inappropriate workplace behaviour including bullying and harassment.

Boards reported, as outlined in Part 2, that they require greater support to understand how to monitor and respond to bullying and harassment, including meaningful performance indicators. Leadership is required from DHHS, WorkSafe and VPSC to develop and promote predictive indicators that provide a consistent way for the health sector to monitor and benchmark workplace culture, including the risk of bullying and harassment.

Recommendations

That WorkSafe, the Victoria 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.

RESPONSE provided by the Secretary, Department of Health & Human Services

RESPONSE provided by the Chair, Ambulance Victoria

RESPONSE provided by the Chief Executive, WorkSafe

RESPONSE provided by the Victorian Public Sector Commissioner

RESPONSE provided by the Secretary, Department of Premier & Cabinet