Paradigm lost? Reflections on the effectiveness of NHS approaches to improving employment relations.

The National Health Service in England has largely relied on a human resources trilogy of policies, procedures and training to improve organisational culture. Evidence from four interventions using this paradigm-disciplinary action, bullying, whistleblowing and recruitment and career progression-confirms research findings that this approach, in isolation, was never likely to be effective. An alternative methodology is proposed, elements of which are beginning to be adopted, which is more likely to be effective.

Root cause analysis in the NHS: time for change?

Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation. A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety. The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised. If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided.

Mind the workplace hazards.

Expecting nursing staff to work in an unsafe environment puts employees and patients at risk of harm. Employers are required by law to protect everyone on their premises, but some still fail to comply. This article provides a guide to the rights and responsibilities of employers, managers and employees.

Stop the bullies.

This article offers guidance on how to speak out if you are the victim of bullying or harassment, or you see a colleague being abused. The problem is widespread, with one in seven respondents to the 2011 NHS staff survey saying they had experienced bullying, harassment or abuse.

Safe to delegate?

Some employers are delegating tasks to less qualified staff. This can present problems for nurses, who are accountable for work they pass on, and who may be asked to perform tasks without adequate training. This article sets out what to do in such circumstances.

Whistleblowing duties.

Nurses and midwives have a legal obligation to raise concerns when patient care is compromised, but doing so is problematic. This article explains how to speak out when nursing staff are being spread too thinly or the skill mix is too weak.

Stand up and be an agent for change.

Why did so few nurses raise concerns about Stafford Hospital? The Francis inquiry reminds individual nurses and their managers of their duties. Nursing Standard begins a series of articles that will help nurses challenge those in charge.