Table 5 Strategies used to reduce, mitigate or prevent UB and associated programme theories. Evaluated and unevaluated strategies are highlighted separately
Strategy | Description | All interventions drawing on the strategy (evaluated) or example sources which mention the strategy (unevaluated) | Programme theories for strategy categorya |
|---|---|---|---|
1. Direct or indirect approach to instigator (victim, bystander or managers) – Evaluated | CMOC 7. Direct or indirect informal approach When feeling psychologically safe (C1) approaching an instigator directly (R) can provide an opportunity for the instigator to hear about what is perceived as UB and reflect (M1) which may cause them to change their behaviours to be less likely to engage in UB in the future (O1) CMOC 8. Engaging with formal processes (e.g human resources or reporting system) When an informal approach either has not worked (C1) or it feels psychologically unsafe to informally approach an instigator (C2) then taking a more formal approach (e.g. using a reporting system (R)) may increase an individual’s/instigator’s perception of risk when behaving unprofessionally (M) and thus reduce their future UB (O) | ||
Informal resolution | Approaching an instigator individually, or their line manager, to try to prompt reflection about behaviour, change future behaviour, or resolve situation | ||
Disciplinary action | Process of an individual being identified as problematic and disciplinary action taken against them by managers. Usually combined with reporting system of sorts | ||
Peer messengers | Peer messengers deliver reports about UB to potential instigators, on behalf of other people who have been targeted and submitted a report to a reporting system | ||
1. Direct or indirect approach to instigator (victim, bystander, or managers)—Unevaluated | |||
Mediation (unevaluated) | Victim and instigator try to resolve their differences with aid of a trained mediator who creates safe environment for discussion | ||
Changing / softening language (unevaluated) | Attempts to change or soften language when reporting mistakes made by clinicians | [52] | |
Speaking up (unevaluated) | Going to a person (e.g. Freedom to speak up Guardian) [180] or authority to report the incidence of UB in an organisation, or could be simply to state in the moment that one is uncomfortable with someone’s behaviour. Requires adequate psychological safety | ||
2. Improving confidence to come forward (victim, bystander)—Evaluated | CMOC 9. Improving confidence to come forward Use of role-playing, cognitive rehearsal strategies, or keeping records as an individual (R) to encourage speaking up about UB (C) can lead to improved self-confidence when coming forward (M) which can lead to the victim speaking up (O1), the instigator reducing their UB (O2) and increased management awareness of UB (O3) | ||
Assertiveness training | Training intended to boost self-confidence and increase people’s ability to challenge UB as it happens | ||
Role playing | Similar to cognitive rehearsal, role playing involves practicing resolution behaviours and thoughts with others in group setting. May enhance ability to cope or improve confidence to come forward | ||
Cognitive rehearsal | Learning of specific cognitive responses to prepare staff when they encounter UB. Intended to move responses from automatic towards deliberated to enhance coping and reduce escalation [73] | ||
Keeping records | Recording incidences of UB and details of the events to provide evidence/improve trustworthiness when coming forward to make a claim against people | [111] | |
3. Improving ability to cope with UB (victim, bystander) – Unevaluated | CMOC 10. Improving ability to cope with UB Use of coping strategies, such as seeking help externally, journalling, reflection, or other individual actions (such as taking sick days) (R) in a situation where one is experiencing UB (C) can lead to an increased ability to cope (M) thereby reducing the impact of UB on the victim’s psychological wellbeing (O) | ||
Seeking help externally (unevaluated) | Looking outside one’s organisation for help with UB, e.g. union representative, regulatory body, or GP | ||
Journalling (unevaluated) | Reflective writing about one’s experience of UB in the workplace may help with coping | ||
Moving victims (unevaluated) | Moving victims away from instigators in organisation | ||
Individual coping strategies (unevaluated) | Various strategies to help improve coping. e.g. taking sick days, hiding emotions/ breathing exercises | ||
Reflection (unevaluated) | Engaging in self-reflection or group reflection to enhance ability to cope, e.g. Schwartz rounds | ||
4. Understanding prevalence of UB (managers/leaders)—Evaluated | CMOC 11. Understanding prevalence of UB Implementing strategies to understand prevalence of UB, such as performing an audit of an organisation’s culture (R) in an organisational environment where UB is suspected to be prevalent (C), can enable managers to have a better understanding of contributors and where UB is occurring (M1), increase knowledge about interventions that might help (O2) and provide a sense of urgency to tackle UB (M3), leading to better ability to target strategies towards core contributors to UB (O1) which can improve effectiveness at reducing UB (O2) | ||
Survey | Survey to identify the level of UB occurring within an organisation which may help to target or design other strategies | ||
4. Understanding prevalence of UB (managers/leaders)—Unevaluated | |||
Multisource feedback (unevaluated) | Similar to reporting systems, but identifies/ investigates individuals from different perspectives—“360-degree” view of individual’s historical behaviour | [103] | |
5. Improving teamwork (all)—Evaluated | CMOC 12. Improving teamwork Implementing interventions to improve teamworking (R) in an environment with low levels of social support (C) can increase empathy between staff, improving the sense of being supported by others (M1) and improve ability to communicate (M2) thereby reducing chance of experiencing conflict with colleagues (O1) and reducing UB (O2) and increasing ability to cope (O3) | ||
Teambuilding exercises | Generally group sessions which incorporate activities to build a sense of social support and camaraderie | ||
Conflict management training | Training to be able to de-escalate situations or avoid escalating them altogether | ||
Communication training | Training to enhance ability to communicate in a way which is less likely to be interpreted as, or foster, UB | ||
Journal club / group writing | Writing as a group, often to reflect on experiences of UB and to build a sense of social support | ||
Problem-based learning | Group learning which involves identifying with and attempting to tackle real-life problems. It often involves peer-to-peer teaching | [143] | |
5. Improving teamwork (all)—Unevaluated | |||
Staff networks (unevaluated) | Establishing internal or external networks for staff from specific backgrounds (e.g. minority ethnic or female) to share coping strategies/improve social support | [148] | |
6. Social norm-setting (all)—Evaluated | CMOC 13. Social norm setting strategies When/if leaders are seen to embody and enforce positive behavioural norms (C), then implementing social-norm setting strategies such as a code of conduct or positive role-modelling (R) can signal culture change towards civility (M1) making it socially unacceptable and therefore riskier to engage in UB for instigators (M2) thus increasing the sense of psychological safety (O1) and reducing the likelihood of UB occurring (O2) | ||
Championing | Encouragement for certain individuals to espouse anti-UB values and behaviours, and, sometimes, to act as trusted contacts for reporting UB incidents | ||
Code of conduct | Document which clarifies organisational policies on acceptable behaviour and processes to report or otherwise tackle UB | ||
Role modelling | Similar to championing, leaders or managers seeking to espouse the behaviours and values they want to encourage in staff | ||
6. Social norm-setting (all)—Unevaluated | |||
Environmental modification (unevaluated) | Modifying physical environment can increase awareness of UB (e.g. posters) or reduce discomfort (i.e. more comfortable temperature) which may reduce UB | ||
Allyship (unevaluated) | When an individual from a more privileged background publicly comes out in support of less privileged colleagues and actively furthers their cause | [68] | |
7. Improving leadership competence and empathy (managers/leaders)—Evaluated | CMOC 14. Improving leadership competence and empathy In an organisation in which there is substantial pressure on organisational leaders (C1), or where leaders have been perceived to engage in bullying-type management practices (C2), implementing training to improve management skills (R) can enhance ability to better understand effects of behaviours (M1) communicate with employees (M2), and enhance empathy for less senior colleagues , supporting ability to manage compassionately (M3), thereby reducing likelihood of leadership directly contributing to UB (O) | ||
Leadership training | Training to improve management or communication styles so that they are less likely to be perceived as using bullying as a management tactic | ||
7. Improving leadership competence and empathy (managers/leaders)—Unevaluated | |||
Reverse mentoring (unevaluated) | Enables people in senior positions to learn from and understand issues from perspective of people in less senior roles often from under-represented groups | [68] | |
8. External pressure on organisations (managers/leaders)—Evaluated | CMOC 15: External pressure on organisations If there is societal pressure or potential reputational risk for an organisation (R) due to findings of an unsafe culture or prevalence of UB (C) then this can lead to pressure on management to resolve the problem, often speedily (M) which can increase the likelihood of other strategies to address UB being designed, resourced and implemented (O) | ||
Seeking hospital Magnet status | Seeking Magnet status can lead to managers and leaders becoming more focused on addressing a culture of incivility | ||
8. External pressure on organisations (managers/leaders)—Unevaluated | |||
Regulator action (unevaluated) | CQC or regulatory body inspection may identify culture of UB, which can place pressure on managers to tackle UB | ||
Laws (unevaluated) | Legislation may place responsibilities on organisations for ensuring equality and employee wellbeing and safety which increases urgency to address UB | ||
9. Reporting and escalation systems (all)—Evaluated | CMOC 16. Reporting systems In an organisation where people may not feel psychologically safe (C) implementing a reporting system such as those in Ethos or Vanderbilt (R) can provide an alternative means to speak up which feels safer (M1) enabling instigators to be approached and to reflect on their behaviour (M2) which can lead to a reduction in UB (O) | ||
Reporting system | System to report incidences of UB in the workplace. Can be web-based, report to a specific person, or other way. Can be anonymous or not | ||
10. Workplace redesign (all)—Evaluated | CMOC 17. Workplace redesign Adjusting the workplace to give more decision-making power to employees or increasing role clarity (R) in an environment where workplace factors present barriers to performing work tasks (C) can increase a sense of fairness in the workplace (M1) improve psychological safety (M2) improve communication within teams (M3) and improve work engagement and motivation (M4) which can reduce proclivity to engage in UB (O1), increase ability to speak up (O2) and improve psychological wellbeing (O3) | ||
Democratisation of workplace | Reorganisation of workplace processes to drive an increased sense of job control, reduce frustration and reduce hierarchy | [108] | |
11. Improving awareness and knowledge (all)—Evaluated | CMOC 18. Improving awareness and knowledge If employees are engaging in UB unknowingly (C1) or are working in an environment where UB is not called out (C) then interventions to increase knowledge and improve awareness (R) can lead to an improved ability to recognise UB (M1) and can lead to reflection about past behaviour (M2), stimulating behaviour change away from UB (O1) likelihood of addressing UB in the moment (O2) and reducing likelihood of UB occurring in the future (O3) | ||
Education, awareness and general group discussions | Training to increase knowledge of what UB look like, how to tackle / increase general awareness of it | [76, 86, 88, 89, 91,92,93, 95, 100, 106, 111, 116, 125, 137, 141, 156, 160, 164, 169, 174, 181] | |
12. Implementation-aiding strategies (managers/leaders)—Evaluated | CMOC 19. Implementation aiding strategies When delivering a complex intervention to reduce UB (R) which requires sustaining over a long period (C), providing time and resource to implement momentum-building strategies can enable greater belief that the programme is an authentic effort to reduce UB, thereby increasing engagement (M1), increasing commitment to the intervention by key actors (M2) and increasing motivation for leaders and managers to implement further strategies to reduce UB (M3) which can increase effectiveness of other strategies to reduce UB (O) | ||
Action planning or goal setting | Staff come together to plan other strategies to tackle UB. Can foster a sense of co-creation | ||
Building a repertoire of strategies | Enables flexible intervention delivery, with repertoire of activities to tackle UB enabling targeted responses to different scenarios | ||
13. Changing recruitment processes (all) – Unevaluated | CMOC 20. Changing recruitment processes Implementing strategies to reduce UB e.g. novel selection methods (R) at the point of recruitment (C) can slowly change the perception of social norm towards civility (M) if the individuals behaving badly leave (C2) which can reduce likelihood of staff engaging in UB (O) | ||
Changing recruitment criteria (unevaluated) | Recruitment criteria to include personality / emotional intelligence tests to decrease recruitment of people who will not flourish in civil organisational culture | ||
Dismissal (unevaluated) | Dismissing instigator known to have UB behaviour from employment | [164] | |