There is an increasing tendency to evaluate the performance of regulators of professions. Most of these evaluations are conducted by oversight bodies, such as the various Superintendents in British Columbia, or by third party consultants retained by the regulators themselves. Most evaluations have focussed on the regulatory effectiveness of the body or the functionality of their governance. A new criterion for evaluation is emerging relating to their internal culture, particularly related to staff.
In the UK, the Nursing and Midwifery Council (NMC) has been the subject of negative media reports based on information provided by a whistleblower. The reports said that the regulator has a toxic internal culture where bullying, racism, and ableism have rendered the NMC dysfunctional. Significantly, it was alleged that the pressure on staff to reduce the enormous backlog in the investigation of complaints has resulted in the inappropriate closure of files related to serious misconduct by nurses and midwives.
The NMC retained external consultants, Rise Associates (Rise), to conduct an Independent Culture Review. Rise reviewed various types of internal NMC files and data, administered an online survey (85% responded), conducted over 200 hours of interviews with current and former staff, held focus groups, and received written submissions. The participation rate was high.
The recently released Rise Report (July 2024) contains disturbing findings. While more than half the staff said they were positively managed, an almost equal proportion reported serious concerns. Their work was emotionally draining. Almost half of all staff had witnessed micro-aggressions in the last 12-months. The whistleblower’s report of bullying, racism, and ableism was widely corroborated. The rate at which staff took medical leave for stress-related reasons or left their employment was alarmingly high. Many felt that reported concerns were not taken seriously and sometimes resulted in retaliation. Multiple concerns were also expressed about cronyism in hiring and promotion decisions. The report says: “We spoke to hundreds of people who were deeply unhappy in their jobs and this is also borne out by key facts and admissions in the HR data and the many staff surveys.”
Perhaps more concerning, from a policy perspective, were the observations about the impact of the internal culture on the “safeguarding” function of the NMC to protect people from harm. Several examples were identified where sexual abuse and child pornography concerns were not acted upon because the acts occurred in non-clinical settings. Another example was the very slow progress made on high profile concerns of physical and mental abuse of vulnerable patients. In addition, the report says:
We also heard of other cases relating to alcohol dependency, racism, inappropriate behaviour with patients and sexual assault that were not acted upon. We have also seen multiple letters and documents where concerns around the handling of these cases have been shared with senior leadership.
Further, there were concerns about the screening of both serious cases and minor issues. Such screening could help prevent nurses and midwives from being left “in limbo” for years. One investigation had been ongoing for nearly ten years and there have been several instances of registrants dying by suicide while undergoing investigation.
The Rise Report makes thirty-six recommendations, several of which dealt with human resource issues that are particularly relevant for large organizations. For example, all managers “should have 360 feedback to inform appraisals, together with feedback from the annual staff survey and other relevant data sources.” Similarly, “Senior leadership [should] engage in reverse mentoring to understand colleagues different lived experiences.” There were also detailed recommendations on developing an Anti-racist Action Plan including a target of appointing “30% of Black and ethnic minority managers so they can better regulate the communities they serve…”
The Report recommends that the NMC create a safe and effective whistleblower mechanism to better identify and address concerns.
Recommendations to address the backlog of complaints included adding more resources such as technology and external assistance. In addition, the NMC should publish timelines for the various stages of their process with public reports on the level of achievement.
In terms of the NMC’s role to safeguard people from harm: “Complex and serious cases should be managed by a specialist team who understand all of the risks involved in not processing these cases appropriately in a timely fashion.” Further, the NMC should ensure “that in all regulatory functions, at every stage, employees have the right knowledge and skills to enable the NMC’s public protection role to be discharged.”
The Rise Report also called for the oversight body, the Professional Standards Authority (PSA), to conduct more rigorous reviews of the NMC. In the post on its website entitled: PSA responds to publication of Independent Culture Review of the NMC, the PSA committed to doing so:
We agree that enhanced monitoring will be required of the NMC in the coming months and years to ensure improvements are implemented and sustained. We will provide an update on how we will achieve this shortly, once we have considered the findings of the review in full. We will also be considering the evidence we look at as part of our performance reviews, and our process overall, to see if these can be further improved to help us identify the sorts of issues raised in the Rise review at an earlier stage.
More generally, the PSA is also considering whether to add an additional standard about the “internal culture, leadership and governance as part of how we assess how well a regulator is delivering on its statutory responsibilities.” This change, if made, would apply to all the regulators that the PSA oversees.
The internal culture of an organization is notoriously difficult to measure or manage but regulators should read the Rise Report for insight and guidance. The external review of a regulator’s internal culture might just become part of their oversight process.
This article was originally published by Law360 Canada, part of LexisNexis Canada Inc, at Law360 Canada.