Evidence synthesis on the occurrence, causes, consequences, prevention and management of bullying and harassment behaviours to inform decision making in the NHS

Background Workplace bullying is a persistent problem in the NHS with negative implications for individuals, teams, and organisations. Bullying is a complex phenomenon and there is a lack of evidence on the best approaches to manage the problem. Aims Research questions What is known about the occurrence, causes, consequences and management of bullying and inappropriate behaviour in the workplace? Objectives Summarise the reported prevalence of workplace bullying and inappropriate behaviour. Summarise the empirical evidence on the causes and consequences of workplace bullying and inappropriate behaviour. Describe any theoretical explanations of the causes and consequences of workplace bullying and inappropriate behaviour. Synthesise evidence on the preventative and management interventions that address workplace bullying interventions and inappropriate behaviour. Methods To fulfil a realist synthesis approach the study was designed across four interrelated component parts: Part 1: A narrative review of the prevalence, causes and consequences of workplace bullying Part 2: A systematic literature search and realist review of workplace bullying interventions Part 3: Consultation with international bullying experts and practitioners Part 4: Identification of case studies and examples of good practic

Interplays of psychometric abilities on learning gross anatomy

In recent years, there has been international debate concerning how students learn anatomy. The rapid increase in scientific knowledge has put pressure on the place of anatomy within the medical and allied health professional curricula, as well as the design and structure of anatomy courses. In this regard, relatively little is known about what medical and allied health professions students want from an anatomy course or how they learn it. To assess students’ learning approaches and perceptions of anatomy, a series of psychometric tests were administered to Medical (n=82), Podiatry (n=21), and Pharmacy (n=74) students in the United Kingdom. Analysis of the Anatomy Learning Experience (ALE) questionnaire revealed a predominantly positive attitude towards anatomy and the dissection room, with most valuing cadaveric dissection and not regarding it as a daunting environment. Further to this, analysis of the Approaches to Studying Inventory for Students (ASSIST) revealed predominant preferences for strategic and deep approaches. Personality traits were associated with certain learning approaches; neuroticism with surface (p=0.038), conscientiousness with both a deep and strategic approach (p=0.000 and p=0.060 respectively). Certain personality traits were also found to be associated with anatomy experience e.g. neuroticism and achievement striving felt the most effective way to learn was to get their hands in and feel for structures (p=0.044 and p=0.012 respectively). This study concludes that undergraduate students of medicine, podiatry and pharmacy learn anatomy in slightly different ways. Preparation for classroom activities should centre on the promotion of an optimum learning environment and teaching strategies which promote a deep approach to learning. Understanding students’ personality and learning experiences should help teachers improve the students’ learning of anatomy for effective application to clinical practice

Workplace bullying: measurements and metrics to use in the NHS. Final Report for NHS Employers.

The aim of this report is to identify how workplace bullying can be tracked over time, to indicate what measures and metrics can be used to identify change, and to provide comparators for other sectors in the UK and internationally. Bullying can encompass a range of different behaviours. Deciding on a definition of workplace bullying can clarify what is regarded as bullying, but it may also narrow the focus and exclude relevant issues of concern. For example, bullying definitions typically state that negative behaviours should be experienced persistently over a period of time. The threshold for behaviours to be defined as ‘bullying’ could be set to include one or two negative acts per month over the previous six months; or more stringently to include only behaviours that occur at least weekly over the previous twelve months. Choosing an appropriate threshold for frequency and duration of behaviours raises several questions: should occasional negative behaviours be regarded as bullying? Would one or two serious episodes of negative behaviour be regarded as bullying? Some researchers use the criteria of weekly negative behaviours over six months to identify bullying, but others argue that occasional exposure to negative acts can act as a significant stressor at work (Zapf et al., 2011). We have identified a range of tools and metrics that can be used to track change over time. However, there are a number of important issues to consider when measuring bullying which may affect the interpretation of the results. In particular, bullying prevalence rates vary considerably depending on the type of metric and definition of bullying used. For example, one international review found prevalence rates ranging from less than 1% for weekly bullying in the last six months up to 87% for occasional bullying over a whole career (Zapf et al., 2011). There are three main types of direct measures of bullying: self-labelling without a definition, self-labelling with a definition, and the behavioural experience method. Self-labelling metrics typically ask a respondent to identify themselves as a target of bullying (e.g., “Have you been bullied at work?” with a yes/no response, or “How often have you been bullied at work?” with a frequency scale such as never/occasionally/monthly/weekly/daily). This approach is quick and easy to administer, but is more subjective as responses will be based on the respondent’s interpretation of bullying. This approach can be improved with the provision of a definition of bullying, and a request to use the definition when responding. However, following pilot work, Fevre et al. (2011) argued that respondents tended not to read and digest bullying definitions as they had already decided what bullying meant to them. The behavioural experience method offers a more objective approach, but is typically longer and more time consuming. This method involves respondents rating the frequency with which they have experienced different negative behaviours (e.g., “How often has someone humiliated or belittled you in front of others?” with a frequency scale such as never/now and then/monthly/weekly/daily). These behavioural inventories may not mention bullying, but capture the prevalence of specific negative acts, and a total score may be calculated. The threshold for the frequency and number of negative acts, or a total score, required for an experience to be regarded as bullying can be chosen by the researcher. Although this enhances the objectivity of the measure, it may be that the respondent themselves may not regard their experience as bullying. In a meta-analysis of bullying studies conducted across 24 countries, Nielsen et al. (2010) found an overall prevalence rate of 18.1% for self-labelling with no definition, 11.3% for self-labelling with a definition, and 14.8% using a behavioural experience checklist. For best practice, it is recommended that both the self-labelling with a definition and the behavioural experience method are used in bullying research (Zapf et al., 2011). It is also important to be specific about the type of bullying being measured. In particular, if the measure is designed to capture bullying at work between co-workers this should be explicitly stated, so that bullying from patients and their relatives is excluded. Interpretation of the results may also be somewhat complex. Although increases in bullying prevalence should undoubtedly be addressed, we need to be mindful that an increase in reported bullying may reflect a change in culture: changing expectations of the behaviour of colleagues and managers, or a move towards greater openness and willingness to address concerns that were previously ignored or condoned. A measure of employees’ trust in the organisation to respond appropriately to such allegations may act as a positive indicator. The perceived and actual anonymity of responses is a critical factor. Employees are understandably wary about providing sensitive information on bullying and have voiced concerns regarding being identified and the potential repercussions of reporting bullying (Carter et al., 2013). There is a considerable discrepancy between the prevalence of bullying as captured in anonymous questionnaires and direct reports of bullying made to the organisation (e.g., to managers or HR; Scott, Blanshard & Child, 2008). Protecting the anonymity of respondents, and ensuring that individuals cannot be identified, will be important factors in the administration of a bullying measure. Some metrics are already routinely collected by the NHS, and if examined closely could provide useful indicators of change. Direct indicators include complaints about bullying and responses to ongoing NHS staff surveys. Indirect metrics can be used to capture factors that are associated with bullying, such as psychological wellbeing (including stress, anxiety and depression), sickness rates, job satisfaction and organisational commitment. However, factors other than bullying will affect these measures. The prevalence of witnessed bullying could also be considered as an important metric. A large proportion of NHS staff report that they have witnessed bullying between staff, and this is associated with negative outcomes for individuals and teams (Carter et al., 2013). Comparing the NHS prevalence rates with other sectors in the UK and internationally is complex. Ideally comparators would have used the same definition, measurement method and reporting period, but the definitions and metrics often differ. Total populations are the ideal, but are rarely provided. Single site studies are less generalisable than multi-site studies, and total samples are preferred over open invitations to unknown populations which may be more likely to attract responses from those who have experienced bullying. This report begins with several definitions of bullying, describes direct and indirect measures of bullying, and compares the prevalence of bullying in the NHS to other sectors in the UK, and to the healthcare sector internationally

Photosynthetic and Respiratory Acclimation of Understory Shrubs in Response to in situ Experimental Warming of a Wet Tropical Forest

Despite the importance of tropical forests to global carbon balance, our understanding of how tropical plant physiology will respond to climate warming is limited. In addition, the contribution of tropical forest understories to global carbon cycling is predicted to increase with rising temperatures, however, in situ warming studies of tropical forest plants to date focus only on upper canopies. We present results of an in situ field-scale +4°C understory infrared warming experiment in Puerto Rico (Tropical Responses to Altered Climate Experiment; TRACE). We investigated gas exchange responses of two common understory shrubs, Psychotria brachiata and Piper glabrescens, after exposure to 4 and 8 months warming. We assessed physiological acclimation in two ways: (1) by comparing plot-level physiological responses in heated versus control treatments before and after warming, and (2) by examining physiological responses of individual plants to variation in environmental drivers across all plots, seasons, and treatments. P. brachiata has the capacity to up-regulate (i.e., acclimate) photosynthesis through broadened thermal niche and up-regulation of photosynthetic temperature optimum (Topt) with warmer temperatures. P. glabrescens, however, did not upregulate any photosynthetic parameter, but rather experienced declines in the rate of photosynthesis at the optimum temperature (Aopt), corresponding with lower stomatal conductance under warmer daily temperatures. Contrary to expectation, neither species showed strong evidence for respiratory acclimation. P. brachiata down-regulated basal respiration with warmer daily temperatures during the drier winter months only. P. glabrescens showed no evidence of respiratory acclimation. Unexpectedly, soil moisture, was the strongest environmental driver of daily physiological temperature responses, not vegetation temperature. Topt increased, while photosynthesis and basal respiration declined as soils dried, suggesting that drier conditions negatively affected carbon uptake for both species. Overall, P. brachiata, an early successional shrub, showed higher acclimation potential to daily temperature variations, potentially mitigating negative effects of chronic warming. The negative photosynthetic response to warming experienced by P. glabrescens, a mid-successional shrub, suggests that this species may not be able to as successfully tolerate future, warmer temperatures. These results highlight the importance of considering species when assessing climate change and relay the importance of soil moisture on plant function in large-scale warming experiments

Workplace bullying in healthcare : A qualitative analysis of bystander experiences

Bystander action has been proposed as a promising intervention to tackle workplace bullying, however there is a lack of in-depth qualitative research on the direct experiences of bystanders. In this paper, we developed a more comprehensive definition of bullying bystanders, and examined first person accounts from healthcare professionals who had been bystanders to workplace bullying. These perspectives highlighted factors that influence the type and the extent of support bystanders may offer to targets. Semi-structured telephone interviews were conducted with 43 healthcare professionals who were working in the UK, of which 24 had directly witnessed bullying. The data were transcribed and analysed using Thematic Analysis. The analysis identified four themes that describe factors that influence the type and extent of support bystanders offer to targets of bullying: (a) the negative impact of witnessing bullying on bystanders, (b) perceptions of target responsibility, (c) fear of repercussions, and (d) bystander awareness. Our findings illustrate that, within the healthcare setting, bystanders face multiple barriers to offering support to targets and these factors need to be considered in the wider context of implementing bystander interventions in healthcare settings. Bystander action has been proposed as a promising intervention to tackle workplace bullying, however there is a lack of in-depth qualitative research on the direct experiences of bystanders. In this paper, we developed a more comprehensive definition of bullying bystanders, and examined first person accounts from healthcare professionals who had been bystanders to workplace bullying. These perspectives highlighted factors that influence the type and the extent of support bystanders may offer to targets. Semi-structured telephone interviews were conducted with 43 healthcare professionals who were working in the UK, of which 24 had directly witnessed bullying. The data were transcribed and analysed using Thematic Analysis. The analysis identified four themes that describe factors that influence the type and extent of support bystanders offer to targets of bullying: (a) the negative impact of witnessing bullying on bystanders, (b) perceptions of target responsibility, (c) fear of repercussions, and (d) bystander awareness. Our findings illustrate that, within the healthcare setting, bystanders face multiple barriers to offering support to targets and these factors need to be considered in the wider context of implementing bystander interventions in healthcare settings

The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study

Background The COVID-19 pandemic has placed unprecedented strain on health-care systems. Frailty is being used in clinical decision making for patients with COVID-19, yet the prevalence and effect of frailty in people with COVID-19 is not known. In the COVID-19 in Older PEople (COPE) study we aimed to establish the prevalence of frailty in patients with COVID-19 who were admitted to hospital and investigate its association with mortality and duration of hospital stay. Methods This was an observational cohort study conducted at ten hospitals in the UK and one in Italy. All adults (≥18 years) admitted to participating hospitals with COVID-19 were included. Patients with incomplete hospital records were excluded. The study analysed routinely generated hospital data for patients with COVID-19. Frailty was assessed by specialist COVID-19 teams using the clinical frailty scale (CFS) and patients were grouped according to their score (1–2=fit; 3–4=vulnerable, but not frail; 5–6=initial signs of frailty but with some degree of independence; and 7–9=severe or very severe frailty). The primary outcome was in-hospital mortality (time from hospital admission to mortality and day-7 mortality). Findings Between Feb 27, and April 28, 2020, we enrolled 1564 patients with COVID-19. The median age was 74 years (IQR 61–83); 903 (57·7%) were men and 661 (42·3%) were women; 425 (27·2%) had died at data cutoff (April 28, 2020). 772 (49·4%) were classed as frail (CFS 5–8) and 27 (1·7%) were classed as terminally ill (CFS 9). Compared with CFS 1–2, the adjusted hazard ratios for time from hospital admission to death were 1·55 (95% CI 1·00–2·41) for CFS 3–4, 1·83 (1·15–2·91) for CFS 5–6, and 2·39 (1·50–3·81) for CFS 7–9, and adjusted odds ratios for day-7 mortality were 1·22 (95% CI 0·63–2·38) for CFS 3–4, 1·62 (0·81–3·26) for CFS 5–6, and 3·12 (1·56–6·24) for CFS 7–9. Interpretation In a large population of patients admitted to hospital with COVID-19, disease outcomes were better predicted by frailty than either age or comorbidity. Our results support the use of CFS to inform decision making about medical care in adult patients admitted to hospital with COVID-19

Evidence into practice: evaluating a child-centred intervention for diabetes medicine management The EPIC Project

BACKGROUND: There is a lack of high quality, child-centred and effective health information to support development of self-care practices and expertise in children with acute and long-term conditions. In type 1 diabetes, clinical guidelines indicate that high-quality, child-centred information underpins achievement of optimal glycaemic control with the aim of minimising acute readmissions and reducing the risk of complications in later life. This paper describes the development of a range of child-centred diabetes information resources and outlines the study design and protocol for a randomized controlled trial to evaluate the information resources in routine practice. The aim of the diabetes information intervention is to improve children and young people's quality of life by increasing self-efficacy in managing their type 1 diabetes. METHODS/DESIGN: We used published evidence, undertook qualitative research and consulted with children, young people and key stakeholders to design and produce a range of child-centred, age-appropriate children's diabetes diaries, carbohydrate recording sheets, and assembled child-centred, age-appropriate diabetes information packs containing published information in a folder that can be personalized by children and young people with pens and stickers. Resources have been designed for children/young people 6-10; 11-15; and 16-18 years.To evaluate the information resources, we designed a pragmatic randomized controlled trial to assess the effectiveness, cost effectiveness, and implementation in routine practice of individually tailored, age-appropriate diabetes diaries and information packs for children and young people age 6-18 years, compared with currently available standard practice.Children and young people will be stratified by gender, length of time since diagnosis ( 2 years) and age (6-10; 11-15; and 16-18 years). The following data will be collected at baseline, 3 and 6 months: PedsQL (generic, diabetes and parent versions), and EQ-5 D (parent and child); NHS resource use and process data (questionnaire and interview). Baseline and subsequent HbA1c measurements, blood glucose meter use, readings and insulin dose will be taken from routine test results and hand-held records when attending routine 3-4 monthly clinic visits.The primary outcome measure is diabetes self-efficacy and quality-of-life (Diabetes PedsQL). Secondary outcomes include: HbA1c, generic quality of life, routinely collected NHS/child-held data, costs, service use, acceptability and utility. TRIAL REGISTRATION: ISRCTN17551624