This study highlights the pervasive and complex nature of toxic workplace cultures within the NHS, as experienced by healthcare professionals on Twitter. The findings demonstrate the importance of analysing social media posts to amplify critical voices often absent from more traditional methods of capturing healthcare workers’ opinions, such as staff surveys, offering valuable insights into the complexities of organisational dysfunction. There is an urgent need to tackle a culture of incivility to safeguard staff wellbeing.

I’ve personally experienced toxic culture and behaviour on many occasions, but I found two examples particularly tough to navigate.

The first was more than 20 years ago when I worked clinically in a trust largely staffed by the local population where most colleagues were either related or friends; I lived some distance away and commuted in.

I’d witnessed troubling behaviour from one senior time-served nurse several times, but one day I heard a blatant, serious breach of patient confidentiality between her and another patient. I was shocked and initially didn’t know what to do. I raised it with the nurse involved who laughed at me, and then the sister in charge who told me to just forget it. After much deliberation, I went to the matron in charge of the department. Conversations took place behind closed doors and eventually I was hauled into trust HQ for a formal meeting, alone—the nurse was nowhere in sight. I was accused of causing upset and the nurse had denied any wrongdoing.

In no uncertain terms it was made clear that I should keep my head down and mouth closed if I wanted to remain in post. From that day on my time was made miserable, colleagues closed ranks, stopped talking to me and I was ostracised until the day I left the trust.

Later in my career, at a different trust, a new director was recruited to lead my department. From the start something felt off as several senior leaders quickly left their roles. It became obvious that the director was a bully; we largely worked in open plan offices, and the director thought nothing of shouting at and belittling people in front of everyone, even other directors and the CEO.

It was impossible for senior colleagues not to know what was happening, but no action was taken.

The situation worsened with many people taking sick leave or leaving the trust completely. I came under fire as the director didn’t agree with how I led my team or how we worked, even though our performance was excellent. An external consultant was brought in to identify issues with my practice and help build a case against me. The consultant admitted this to me and said they couldn’t find anything wrong to report back.

At the time I had a mentor relationship with a senior board member, and I chose to confide in them with the hope of gaining some insight into how I might be able to better deal with the situation. I didn’t know until sometime later, but my mentor was informing the director about our conversations.

As time passed, the behaviour worsened and, although many colleagues were experiencing it too, it was obvious I was on my own in wanting to speak up. I was encouraged to go to a senior HR colleague who would be empathetic, so I did and eventually the director agreed to mediation. I was so nervous ahead of the meeting, but it went ahead and to my surprise the director admitted to some of the allegations and agreed some actions.

If I thought my treatment had been bad to this point, I had no idea what was to come. It felt like open season with the director’s full toxicity focussed on me. Derogatory rude emails would be sent daily, raising my anxiety as they landed in my inbox. Meetings where we were both present made me feel sick; they would think nothing of singling me out in front of everyone for their derision and nastiness. The barrage was constant and debilitating, affecting every part of my life and breaking my confidence. One day I couldn’t take any more so left work early and crawled into bed at home where I felt safe.

I decided to call the senior HR colleague who had facilitated the previous mediation to ask for an update about the agreed actions. I was absolutely shocked to my core at their reaction, they shouted down the phone that I’d had my opportunity to air my grievances, nothing more was going to happen, the director wasn’t going to be held accountable for the agreed actions and I just needed to forget it and get on with my job. Was I naive to expect a different response?

I hit rock bottom, felt scared to go into work and knew I had to get out of there for my health and sanity. Even when I left, the impact followed me to my next role; my confidence and resilience were shot and took a long time to rebuild.

The director stayed in post for another couple of years until there were so many grievances that the CEO had to act. The sickening part is that after a period of ‘gardening leave’ the director secured another senior role in another trust in the area so will be perpetrating the same toxic behaviour onto others.

I know there are thousands of experiences throughout the NHS just like mine and, unfortunately, in many organisations culture and behaviours aren’t improving. This problem is endemic and has decades of history behind it.

There is a clear and acknowledged link between toxic cultures and patient safety. Within the NHS Patient Safety Strategy, NHS England states that: "positive patient safety and healthy organisational culture are two sides of the same coin. A culture in which staff are valued, well supported and engaged in their work leads to safe, high-quality care." In order to improve the care delivered to our loved ones, friends and ourselves, the NHS must take action to improve its culture.

Forget the financial situation and the waiting lists, this is the most pressing and wicked problem facing our health service today; it permeates throughout everything and unless it is acknowledged, challenged and cured no other interventions will work. Money doesn’t solve toxic cultures, neither does restructuring the NHS for the umpteenth time.

Sadly, some colleagues have taken their own lives because of the toxicity they have endured, this needs to stop now. There are no easy answers here but if we don’t put this right the NHS won’t survive.

Share your story

Have you worked in a toxic culture? Have you tried to speak up? Have you examples of a good team culture?

Add your comment below (you will need to be a hub member and signed in) or contact us at content@pslhub.org and we can share your story anonymously.

Related reading on the hub

• Speaking up for patient safety: A new interview series about raising concerns and whistleblowing
• Speaking up as an agency nurse cost me my career
• My experience of speaking up as a healthcare assistant in a care home

Principle 1 – Culture of safety

Every organisation involved in providing NHS healthcare should actively foster a culture of safety and learning in which all staff feel safe to raise concerns.

How can you describe a culture?  What does it look like?  I am sure that there has been many an hour at board meetings discussing this very subject. Describing the ideal safety culture is easy, we are told to adopt a ‘just culture’, however fostering a culture of safety is not that simple, following a guide doesn’t work.

‘Fostering a culture’ means to nurture and support a way of working. This principle also asks for Trusts to ‘actively foster’, to me this means that it is a dynamic action. It is not just a ‘thing’ that is said, but a ‘thing’ that you do. Working in the NHS for years, I feel I have become institutionalised, along with middle management. Bad habits are hard to break, we may start out trying to change our behaviours, but the old-world bites back. Its easy to fit in. It feels safer for us to fit in.

There are multiple layers of management. Each layer has its own processes and brings with it its own culture. Hierarchy is steep in the NHS, if you do not go through the correct chain of command, you may be labelled as a troublemaker or whistleblower. 

This principle mentions that ALL staff should feel safe to raise concerns. As a clinician, I have the safety net of my professional body, they will support me. But what about porters, domestic and support staff or volunteers?  Do they feel empowered to speak up? They may feel at the very bottom of this hierarchy.  How are Trusts ensuring that they also have a voice? 

This principle excludes the most important group. Patients. Why are Trusts not empowering patients to speak up? Why are there no robust mechanisms for them to speak up? It is not just staff that need to feel safe in speaking up, it's patients and their families.  

Principle 2 – Culture of raising concerns

Raising concerns should be part of the normal routine business of any well-led NHS organisation.

I have raised concerns where I work, as I am sure we all have. We do it via Datix. There is a usual process. We spot the harm/concern and we log it on the computer. It gets graded by the safety team and we hear nothing back.  It then happens again and the cycle repeats. This within normal behaviour. This is normal routine.

Many staff are not happy with this routine of raising concerns. They have taken the effort to take the time to log the concern but feel disengaged when they hear nothing back. So why bother? They bother because it is to cover themselves and they also bother in the hope that improvements will be made.

However, what if these concerns are larger. What if these concerns you have are a system wide problem? Datix is not always the correct route, it doesn’t fit.

You can alert your manager, who then will alert their manager and so it goes up the chain. If at any point you feel you are not being listened to you can then go and see your Freedom to Speak Up Guardian (FTSUG). Sounds ideal.   

Some FTSUG work part time, some work clinically on top of this role. They are not always easily accessible.  I am unclear on what value they bring to an organisation. What changes can they make? Are they listened to? Have they been put there to ‘tick the box’? 

Principle 3 – Culture free from bullying

Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours.

I have raised concerns where I work.  If I follow the usual routine of raising concerns, all is good. Nothing happens.

If I raise a concern outside of the normal routine, this is where the problems start.

Reflecting back on a time when I raised a concern about three wards and their lack of equipment, I raised the concern with the Matron and the Patient Safety lead. More equipment needed to be purchased to prevent harm from happening to patients. This equipment was needed urgently, and I felt that the Datix system would take too long and harm would have happened before the problem was addressed.

I received an email from the Head of Nursing for that area, defending why there was a lack of equipment and that I was wrong for emailing the Matron and the safety lead, that I went through the wrong channels and that she would like to see me to discuss the matter.

Of course, I accepted the offer of meeting up. After all, what had I done wrong? Emailed the wrong person? Raised a concern? Had I spoken out of turn? 

When I received this email I felt upset and scared, then angry. This was bullying behaviour from a senior member of the Trust.  

I then thought, why?  

The Head of Nursing was known to me. She has been a real inspiration to me, so what has happened? This must be a cultural way of coping with concerns that are directly involved in the way she had managed this area. Now she was being faced with a concern raised by someone low down in the ranks, which could possibly look like an attack on the way she manages this area.

Was she annoyed that she wasn’t involved in the email trail? Whatever it was, the way that the concern was raised was out of the usual. It upset the way we do things round here.

I don’t want to be labelled as a whistleblower. I am doing my job and doing what the board have asked. I am raising concerns.  

As you see this blog is anonymous. The fear of vilification is strong and is very real.

And all this with an issue where my intervention prevented a never event and for which I was thanked. 

With this experience, will I raise concerns again in real time to prevent harm? Or will I choose to go through the official route, wait and see if anything happens and be ready to explain (if asked) when the Trust undertakes a serious incident investigation or defends a clinical negligence claim? 

Principle 4 – Culture of visible leadership

All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff.

Initiating the FTSUG in every NHS Trust was a great idea, however, if we had visible leadership that welcomed and encouraged raising of concerns, we would not need this service.

The FTSUP is a sticking plaster for a deeper routed problem.

The Head of Nursing had a very human response to my concerns. She was defending actions that others had taken and defending why the problem happened. This is a natural reaction to feeling threatened, so perhaps I was in the wrong in the tone in which I raised the concern?

This led me to question what training middle managers have on dealing with staff or patient concerns. When confronted with a concern do they know what to do? What do they do with this knowledge, how do they communicate with the staff or patient raising the concern? How do they raise up the line with their directors and the Board? Will they be thanked for highlighting opportunities to improve or will they be met with defensiveness and hostility? 

And what about ‘raising concerns’ training for staff and patients? We also need to know what is expected of us and what we can expect back, that someone has our back when we raise concerns.

Principle 5 – Culture of valuing staff

Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified.

If adequate training in this area existed perhaps more staff and patients would speak up as they feel that they were being heard, being cared for and feel safe. In turn, middle management would feel more equipped to handle concerns with a more inquisitive approach rather than one of defence.

Being involved in improvements in care is a wonderful experience. Seeing that you have made a difference to patients is a privilege.

We need to react to people raising concerns in a different way, using a different lens and we all need the training and support to do so.

What are Trusts doing to show that raising concerns is welcomed, makes a difference and helps us improve safety? Shouldn’t this be publicly reported to staff, to commissioners and the general public?

Principle 6 – Culture of reflective practice 

There should be opportunities for all staff to engage in regular reflection of concerns in their work.

Reflections of our concerns for work could be taken as evidence, this has been seen in the Dr Garber incident. This has made us fearful of writing our reflections down.

Shwartz rounds are great but take a lot of organising and are only for the few staff.  

Time will always be an issue, so quick-fire reflections about what has gone wrong, and even better what has gone right, with your immediate team are a fantastic opportunity. 

We try and have after action reviews, however the harsh reality of clinical practice does not lend itself to a half a dozen staff downing tools to talk about just what happened.  The capacity to do this is just not there.

I am reflecting now on concerns that I have raised.  It’s a shame I don’t feel confident in putting my name to this blog for fear of what my Trust will say.

As I said, I do not want to be a whistleblower, none of us do. We want to raise concerns, have them acted on and keep our patients safe.

Call for action 

At present the conditions are not right for us to speak up safely for these reasons:

• Our current reporting process doesn’t fit large system wide concerns, this is set up for incidents that have already harmed patients or staff.
• A Just Culture approach is spoken about but is not demonstrated or welcomed when concerns are raised.
• Staff are not equipped to handle concerns once they are raised to them.
• Patients or staff are not encouraged to speak up or have the mechanism to do so.
• Taking time out to reflect on our concerns and our practice is not valued.

There are some great initiatives out there, but unless the fundamentals are in place to allow safe speaking up repeated harm will continue to happen.

• Language influences the perceptions of the accident process.
• The use of punishment can be harmful to individuals.
• Punishment does nothing to help achieve future safety.
• Accident analyses are not independent from the organisation politics.