There is, finally, a growing awareness of the impact of race discrimination on Black and Minority Ethnic patients. Not so well known is the impact of workforce race discrimination on patient care and safety. For leaders determined to improve the quality and safety of patient care, tackling workplace race discrimination is not an optional extra.
We have a wealth of data demonstrating that the 250,000 Black and Minority Ethnic (BME) NHS staff are disadvantaged in recruitment and career progression, disciplinary action, bullying and harassment, and if they raise concerns. Such discrimination has serious consequences for patient care and safety.
The NHS ethnicity gradient means BME staff are scarcer the more senior the post. It is still 1.61 times more likely that a White shortlisted candidate will be appointed compared to a BME shortlisted candidate. Selection panels still choose “people like us” or who can best “fit in”, thus depriving patients of the best possible talent.
NHS BME staff are more likely than White staff to be disciplined. BME doctors, nurses and midwives are all more likely to be reported to their professional regulator by their employer, though interestingly, not by the public (1). Such treatment, exacerbated by the risk of racial bias in investigations, means that mistakes we all make are more likely to be seen through the lens of blame not learning for BME staff, especially given the difficulty some White managers have in having honest conversations with BME staff when mistakes do happen.
28% of NHS BME staff were bullied by managers and colleagues last year (23% of White staff were) and are 2.5 times more likely to report being discriminated against than White colleagues according to the most recent NHS staff survey. Bullying affects both physical and mental health (2) and adversely impacts performance, career progression, engagement, retention and team effectiveness with a cost conservatively estimated at 2.3 billions a year to the NHS in England (3). Bullied staff are less likely to admit mistakes, raise concerns or work effectively in teams – all with consequences for patient care and safety (4).
Robert Francis found very significant differences between the experiences of White and BME staff who raised concerns. BME staff had much poorer responses when they raised concerns, were more much more likely to feel victimised by management or co-workers for doing so and were then less likely to raise concerns again, all then likely to directly impact on patient care and safety. National staff survey data suggests such significant differences remain.
Race discrimination makes people ill. Two decades ago Nazroo and Karlsen found that: “over and above socioeconomic effects, both experience of racial harassment and perceptions of racial discrimination make an independent contribution to health. For example, those who had been verbally harassed had a 50 per cent greater odds of reporting fair or poor health compared with those who reported no harassment” (5).
Race discrimination is positively associated with an extensive range of adverse conditions including coronary artery calcification, high blood pressure, lower birth weight, cognitive impairment, and mortality. Discrimination, like other stressors, can affect health through both actual exposure and the threat of exposure. Feeling excluded leads to higher rates of depression and psychological alienation, poorer cognitive functioning, impaired motivation, and poorer physical health. The need to belong is thus a powerful human motive (6).
Dawson found strong correlations between the experiences of BME staff at work and patient satisfaction. Crucially, racism and bullying undermine psychological safety at work. This matters because, as demonstrated, inclusive and compassionate leadership helps create a psychologically safe workplace without staff are less likely to listen and instead with staff who support each other, thus resulting in fewer errors, fewer staff injuries, less bullying of staff, reduced absenteeism and (in hospitals) reduced patient mortality (7).
Inclusive organisations are more likely to be ‘psychologically safe’ workplaces where staff feel confident in expressing their true selves, raising concerns and admitting mistakes without fear of being unfairly judged (8). Where Black and Minority Ethnic staff are not welcomed, their difference not valued, and it is not a safe place for them to raise concerns or admit mistakes, then patient care is likely to suffer. Yet when more diverse representation is underpinned by inclusion, demographic diversity can significantly improve creativity, innovation and productivity (9).
The cumulative impact of race discrimination on staff welfare was highlighted during the COVID-19 pandemic when BME staff were more at risk as they worked disproportionately in lower-graded patient facing roles, had poorer access to appropriate PPE with the correct fit, were more reluctant to raise concerns and were disproportionately redeployed to riskier areas (10). The resultant impact on staff health and safety in turn impacted staff sickness, staff long-Covid levels, staff morale and probably turnover risking patient safety and the quality of care, not just staff welfare.
Tackling racism is a moral issue. It is a breach of staff contractual rights. Employers have a duty of care and a statutory duty to address the drivers of staff discrimination. But tackling race discrimination and promoting respect and equity across racial difference is also a crucial part of improving patient care and safety whatever the ethnicity of the staff involved.
A version of this article formed a presentation to The Healthcare Improvement Studies Institute conference 2021.
(1) Atewologun, D, Kline, R (2019). Fair to refer. GMC. (2019). A similar pattern exists for NMC referrals. See also West, Elizabeth West et al; The progress and outcomes of black and minority ethnic (BME) nurses through the Nursing and Midwifery Council’s “Fitness to Practise” process: Final report. Greenwich University for the NMC.
(2) Lever, I et al. (2019) Health Consequences of Bullying in the Healthcare Workplace: A Systematic Review. December 2019 Journal of Advanced Nursing 75(12).
(4) Leape, L. et al (2012). A Culture of Respect, Part 1. The Nature and Causes of Disrespectful Behavior by Physicians Academic Medicine: July 2012 – Volume 87 – Issue 7 – p 845-852.
(5) Karlsen, S and Nazroo, J (2002). Agency and structure: the impact of ethnic identity and racism on the health of ethnic minority people Sociology of Health and illness Volume 24, Issue1 2002 Pages 1-20.
(6) Baumeister R Leary, M (1995). The Need to Belong: Desire for Interpersonal Attachments as a Fundamental Human Motivation Psychological Bulletin 117(3):497-529
(7) Carter, Mathew et al (2008) Developing Team Based Working in NHS Trusts. Report prepared for the Department of Health November 2008
(8) Shore, L et al (2018) Inclusive workplaces: A review and model. Human Resource Management Review 28 (2018) Pp 176-189
(9) Scott E Page (2017). The Diversity Bonus: How Great Teams Pay Off In The Knowledge Economy. Princeton.
(10) Kline, R. (2020) COVID-19: What employers do (or don’t do) makes a big difference. Race Equality Foundation.
Roger Kline is Research Fellow at Middlesex University Business School. He authored “The Snowy White Peaks of the NHS” (2014), designed the Workforce Race Equality Standard (WRES) and was then appointed as the joint national director of the WRES team 2015-17. Recent publications include) the recent report Fair to Refer (2019) to the General Medical Council on the disproportionate referrals of some groups of doctors (co-authored with Dr Doyin Atewologun) and The Price of Fear (2018), the first detailed estimate of the cost of bullying in the NHS, co-authored with Prof Duncan Lewis.
Declaration of interests
I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.