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In this blog, Clare Wade, Patient Safety Learning's Director, draws attention to the impact toxic cultures have on staff and how, sadly, most often nothing is done about it. Clare shares her own personal reflections from past experiences in her career. There is a clear link between toxic cultures and patient safety, and while there are no easy answers these behaviours must be acknowledged, challenged and cured if the NHS is to survive. 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 [email protected] 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

In this blog, Patient Safety Learning’s Associate Director Claire Cox looks at how corridor care within the NHS is affecting safety culture, examining its implications for both healthcare professionals and patients. She underlines the need to understand these dynamics so that we can identify strategies to address causes of corridor care and promote a culture that prioritises safety and high-quality care for all. Corridor care is a term used to describe the practice of providing medical attention to patients in hallways or other non-designated clinical areas due to overcrowding or resource shortages. In the context of the NHS, this phenomenon has become increasingly common due to rising patient demand, workforce challenges and limited bed capacity.[1] While corridor care may seem like a necessary stopgap measure to address acute pressures on healthcare services, it raises significant concerns about patient dignity, privacy and the overall quality of care. We set out these issues in more detail in a blog published earlier this month reflecting on the extent of corridor care in the UK.[2] Corridor care reflects deeper systemic issues within the NHS, including funding constraints, staffing shortages and inefficiencies in patient flow. Its growing prevalence has led to widespread debate about its impact not only on patient outcomes but also on the morale and functioning of healthcare teams. Safety culture An organisational culture that seeks to assign blame when things go wrong makes patient harm more likely to happen again. In our report, A Blueprint for Action, we identify just culture as one of the six foundations of safer care to improve patient safety.[3] A just culture considers wider systemic issues when things go wrong, enabling professionals and those operating in the system to learn without fear of retribution. Just culture aligns with creating a safety culture, where shared values, attitudes and behaviours within an organisation prioritise safety as a fundamental component of its operations. In healthcare, a strong safety culture is critical to minimising risks, preventing harm and ensuring that patients receive the highest standard of care. Published in July 2019, the NHS Patient Safety Strategy identifies a patient safety culture as one of the two core foundations required in working towards its safety vision “to continuously improve patient safety”.[4] Safety culture directly influences how staff respond to pressures, make decisions and balance competing priorities. When safety culture is strong, staff feel empowered to speak up about concerns and systems are in place to mitigate risks. However, practices like corridor care can undermine these principles by creating environments where safety is compromised, staff morale declines and patient outcomes suffer. Corridor care and safety culture: Impact on teams Corridor care significantly affects safety culture among different healthcare teams, including ambulance staff, ward staff and emergency department (ED) staff. These groups must collaborate in high-pressure, resource-limited environments where patient safety is already at risk. However, the dynamics created by corridor care can undermine trust, communication and efficiency, all of which are critical components of a strong safety culture. Ambulance staff Ambulance staff are often the first point of contact for patients entering the healthcare system. When EDs are overcrowded and patients are treated in corridors, ambulance staff may face delays in transferring patients to hospital care. Long ambulance handover delays have been a persistent component of the problems faced by the NHS in recent winters.[5] [6] [7] Prolonged handover times can prevent ambulance crews from responding to new emergencies, creating frustration and moral distress. Corridor care also limits the ability of ambulance staff to provide a full clinical handover, leading to communication breakdowns and potential gaps in patient care. These delays can result in tension between ambulance crews and ED staff, as both teams struggle to manage their workloads under significant pressure. The lack of structured processes during corridor care undermines teamwork and fosters an environment where safety protocols may be bypassed to save time. Emergency department staff ED staff endure the most of corridor care's challenges, as they are tasked with managing patients in overcrowded spaces. The need to oversee patients in hallways stretches resources and divides attention, making it harder to maintain comprehensive monitoring and timely intervention. This environment increases the likelihood of errors and reduces the capacity to provide high-quality care. The presence of patients in corridors can also create role ambiguity and conflict between team members, as the usual boundaries between clinical responsibilities become blurred. For example, junior staff might feel unsupported when managing corridor patients, while senior staff may struggle to oversee all aspects of care effectively. The resulting stress and burnout among ED staff can weaken safety culture by diminishing morale, collaboration and the willingness to speak up about concerns. Ward staff Ward staff are often involved in the downstream effects of corridor care when patients are eventually transferred from ED corridors to inpatient wards. These staff members frequently face increased pressure to admit patients quickly to alleviate ED overcrowding, potentially without adequate preparation or information. This rushed process can compromise continuity of care and increase the risk of adverse outcomes. Many Trusts are now admitting an extra patient onto the wards to alleviate ED pressures, which also has implications for safety, privacy and dignity. Moreover, the systemic strain caused by corridor care can exacerbate existing tensions between ward staff and ED teams. Ward staff may perceive themselves as being unfairly burdened, while ED teams may feel unsupported in their efforts to manage patient flow. This misalignment can erode interdepartmental relationships and hinder the development of a cohesive safety culture. Corridor care and safety culture: Impact on inter-team collaboration Corridor care amplifies the challenges of inter-team communication, trust and collaboration, all of which are essential to maintaining a robust safety culture. When teams operate in silos or perceive themselves as competing for limited resources, it becomes harder to prioritise patient safety as a shared responsibility. The relationship between safety culture and corridor care is deeply intertwined; safety culture can be significantly undermined by the systemic and operational challenges posed by corridor care. Understanding this connection is essential to addressing the negative impact of corridor care on patient safety and team dynamics. This can be seen when considering how core principles associated with safety culture compare with the realities posed by corridor care: Open communication: A strong safety culture relies on clear communication among teams to ensure patient needs are met and risks are minimised. However, in the context of corridor care, chaotic and overcrowded environments can hinder effective communication. Ambulance staff may not have the opportunity to provide thorough handovers, ED staff may miss key patient details in the rush and ward staff may receive incomplete or delayed information about incoming patients. These communication breakdowns increase the risk of errors, undermining safety culture and compromising patient safety. Teamwork and collaboration: Safety culture emphasises collaboration across all levels of healthcare. Corridor care disrupts this by placing teams under excessive strain, leading to interdepartmental tensions. For example, ambulance staff may feel unsupported during prolonged handovers, while ED staff are overwhelmed managing corridor patients. This strain and associated incivility erode trust and reduces the cohesion necessary for a positive safety culture. Proactive risk management: A proactive safety culture involves identifying and mitigating risks before they lead to harm. Corridor care creates environments where risks—such as patient deterioration, falls and inadequate monitoring—are more likely to occur. The lack of resources and time for proactive measures further weakens the ability to uphold safety standards. As well as coming into conflict with some of the core principles of a safety culture, corridor care can also erode this further by: Compromising patient safety: Corridor care forces healthcare professionals to provide care in suboptimal conditions, where monitoring equipment, privacy and basic patient needs are often lacking. This creates a pervasive sense of vulnerability among staff as they are unable to deliver the standard of care they aim to achieve. Over time, this can normalise unsafe practices and dilute an organisation’s safety culture. Increased stress and burnout: Staff operating in these environments experience heightened stress and emotional exhaustion, which can lead to burnout. Burnout can negatively impact engagement, communication and decision making—all critical components of safety culture. Blame culture: In the absence of systemic solutions to corridor care, a culture of blame may develop. Teams or individuals may be scapegoated for adverse outcomes, discouraging the reporting of safety concerns. A blame culture directly contradicts the transparency and learning focus that underpin a strong safety culture. Undermining the opportunity to learn from staff speaking up: In a pressurised environment, staff may not feel that they have the time or confidence that their concerns about unsafe care will be welcomed or listened to. It is important that both healthcare providers and system leaders understand the reality of delivering corridor care and its patient safety consequences. This requires staff to be supported to raise issues through formal reporting systems, contribute to patient safety incident reviews and investigations, and speak up when they need to do so in line with their professional responsibilities. As noted earlier, corridor care often reflects deeper systemic issues, such as funding constraints, staffing shortages and inefficiencies in patient flow due to multifactorial issues outside of the control of an individual organisation. Systemic factors that challenge the ability of healthcare organisations to maintain a robust safety culture can include: Overcrowding in emergency departments—this can be a symptom of wider systemic problems—mental health crisis, an aging population, unaddressed health inequalities, access to primary care, staffing and funding crisis, etc. Insufficient staffing levels and expertise—resulting in compromised care and reduced opportunities for collaboration, communication and oversight with systems in place to review patient acuity and appropriate escalation. Limited resources—preventing the implementation of solutions, such as expanding capacity or improving triage processes, further entrenching corridor care as a stopgap measure. When systemic problems are not addressed, staff may feel disillusioned, which may undermine their commitment to the principles of safety culture. Corridor care and safety culture: What can be done? Maintaining a safety culture is an essential component of keeping patients safe from avoidable harm. In the current circumstances where corridor care is increasingly prevalent in the NHS, this is now more important than ever. This can be supported by: Encouraging open reporting and speaking up: Creating a non-punitive environment for reporting safety concerns allows teams to identify risks associated with corridor care and work collaboratively to address them. Improving communication: Structured handover protocols and enhanced use of digital tools can ensure critical patient information is not lost, even in corridor settings. Fostering interdepartmental collaboration: Training sessions, joint meetings and shared goals can build trust and reduce tensions between ambulance, ED and ward staff. Investing in staff well-being: Providing mental health support and ensuring adequate staffing levels can alleviate burnout, enabling staff to uphold safety principles. At Patient Safety Learning we are clear that corridor care must not become the norm. The negative effects on staff, patients and families can be significant and long lasting. This requires action from healthcare leaders, not only to support real time improvements, but to identify the deep-rooted causes and commit to longer-term solutions. References 1. Royal College of Nursing. On the frontline of the UK’s corridor care crisis, 16 January 2025. 2. Patient Safety Learning. Response to RCN report: on the frontline of the UK’s corridor care crisis, 17 January 2025. 3. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 4. NHS England, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. 5. Discombe, M. Ambulance handover delays hit record high. Health Service Journal, 9 January 2025. 6. Nuffield Trust. Ambulance handover delays, 25 April 2024. 7. Health Services Safety Investigations Body. Harm caused by delays in transferring patients to the right place of care, 24 August 2023.

In this podcast episode, hosts Liz Jones and Darren Kilroy from RLDatix speak to Helen Hughes from Patient Safety Learning about how people, technology, and healthcare come together to create great experiences and support patient safety. The Connection: Where Tech Meets Humanity in Healthcare, is a podcast series from RLDatix, which explores the intersection of technology and human-centred care with the health and care sector. Key talking points from the conversation include: the true scope of patient safety why healthcare leaders must prioritise patient safety how to make patient safety everyone's job essential principles for electronic patient record system implementation.

This article by Jesse Lyn Stoner, argues that leading without relying on authority is a higher evolutionary skill. It supports developing adult relationships based on mutual objectives and creates work environments grounded in respect for human dignity. Stoner outlines “The 8 Portals of Influence” – Ways to Influence Without Authority. Character – Your own character is your greatest source of influence. Do you lead by example and follow through on your commitments? Are you respectful, authentic and trustworthy? People will believe you are motivated by the common good and not personal gain. Expertise – Do you have content knowledge and experience? Are you a thought leader? Do you understand the process needed to accomplish the objective? You can influence by providing a clear logic, an explanation of the benefit, and reassurance that it is the right course of action. Information – Do you have access to valuable information? You can influence by providing data and proof. Connectedness – Do you form close relationships with people? Do they enjoy working with you? Do you engender loyalty? You can influence by appealing to shared values and your emotional connection. Social intelligence – Do you offer insight into interpersonal issues that interfere with work and help facilitate resolution of issues? People trust that you’ll be able to help them work together effectively. Network – Do you put the right people in touch with each other? Can you garner the endorsements of credible people? People will trust that you will get the support needed. Collaboration – Do you seek win-win solutions, unify coalitions and build community? People will trust that you can help them become a high performing team that accomplishes its objectives. Funding – Do you have access to financial support? If financial resources are required, it’s easier to influence when you can ensure adequate funding is available. The below infographic has also been developed in relation to Stoners work. The below image was created by Tanmay Vora. Read the full article by Jesse Lyn Stoner, published by the Seapoint Center for Collaborative Leadership, via the link below.