An ethnographic study exploring the

over-representation of black and minority

ethnic (BME) employees in the disciplinary

process in a National Health Service

(NHS) Trust

by

HarjinderSehmi

A thesis submitted for Doctorate in Clinical Practice

PART ONE

Faculty of Health and Medical Sciences

Division of Health and Social Care

University of Surrey

May 2014

© HarjinderSehmi 2015

Statement of originality

This thesis and its research content are the results of my efforts. Any ideas, data, images or

text resulting from the work of others (whether published or unpublished) are fully identified

as such within the thesis and attributed to their originator in the references. This thesis has

not been submitted in whole or in part for any other academic degree or professional

qualification.

HarjinderSehmi

2 February 2015

1

Contents

Statement of originality.............................................................................................1

Content ......................................................................................................................2

Abstract......................................................................................................................8

Acknowledgements.................................................................................................10

Acronyms.................................................................................................................11

Chapter 1: Introduction........................................................................................141.1 Introduction..............................................................................................................141.2 The NHS....................................................................................................................14

1.2.1 BME employees...................................................................................................151.2.2 Disciplinaries........................................................................................................17

1.3 Overview of the study..............................................................................................181.3.1 Literature review..................................................................................................181.3.2 Methodology........................................................................................................181.3.3 Findings...............................................................................................................181.3.4 Discussion...........................................................................................................18

1.4 Summary...................................................................................................................19

Chapter 2: Literature review.................................................................................202.1 Introduction..............................................................................................................202.2 Accessing the literature...........................................................................................202.3 Search strategy........................................................................................................20

2.3.1 Database searching.............................................................................................212.4 Results from the literature search..........................................................................21

2.4.1 Disciplinaries outside the NHS............................................................................222.4.2 Poor performance, suspensions and disciplinaries in the NHS...........................252.4.3 Presentation of BME staff....................................................................................31

2.4.3.1 Terminology...............................................................................................................322.4.3.2 ‘Black and black’........................................................................................................352.4.3.3 ‘Saviours’, ‘exploited’ and ‘exploiters’?......................................................................362.4.3.4 Overseas staff...........................................................................................................372.4.3.5 Perceptions of behaviours and attitudes of BME staff...............................................38

2.4.4 Organisation and management culture of the NHS.............................................402.4.5 E&D agenda........................................................................................................48

2.5 Summary of literature review..................................................................................522.6 Gaps..........................................................................................................................532.7 Formulation of the research question....................................................................54

Chapter 3: Methodology.......................................................................................543.1 Introduction..............................................................................................................54

Figure 1: Study process and data collection methods.....................................................553.2 Qualitative approach................................................................................................56

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3.3 Research site............................................................................................................573.3.1 Negotiating and gaining access to the Trust.......................................................58

3.4 Ethnography as a methodology.............................................................................623.4.1 Rationale for using ethnography..........................................................................633.4.2 Characteristics of ethnography............................................................................643.4.3 Focused ethnography..........................................................................................643.4.4 Critical ethnography.............................................................................................65

3.5 Core concepts from ethnography..........................................................................663.5.1 Culture.................................................................................................................66

3.6 Methodology.............................................................................................................673.6.1 Fieldwork.............................................................................................................683.6.2 Emic and etic perspectives..................................................................................693.6.3 Secondary data....................................................................................................693.6.4 Participant observation........................................................................................733.6.5 Interviewing..........................................................................................................75

3.6.5.1 Semi-structured interviews........................................................................................763.7 Selection, recruitment and undertaking interviews with participants...................77

3.7.1 Selection – inclusion and exclusion.....................................................................773.7.2 Recruitment.........................................................................................................783.7.3 Special measures taken for employees who had been investigated...................783.7.4 Undertaking interviews........................................................................................793.7.5 Outcomes from the interviews.............................................................................79

3.8 Data recording..........................................................................................................803.8.1 Field notes...........................................................................................................803.8.2 Digital audio recording.........................................................................................813.8.3 Fieldwork journal/diary.........................................................................................82

3.9 Data analysis............................................................................................................823.9.1 Thematic analysis................................................................................................833.9.1.1 Presentation of findings from data collected................................................................... 82

3.10 Triangulation...........................................................................................................853.11 Ethics.......................................................................................................................863.12 Reflexivity...............................................................................................................883.13 Summary.................................................................................................................91

Chapter 4: Descriptive statistics..........................................................................934.1 Ethnic profile of the population the Trust serves.................................................934.2 Workforce profile......................................................................................................94

4.2.1 2011 profile..........................................................................................................954.2.2 2012 profile........................................................................................................100

4.3 Disciplinaries..........................................................................................................1044.3.1 Reasons for disciplinary action..........................................................................108

4.4 Conclusion..............................................................................................................108

Chapter 5: Observation of a disciplinary hearing and interviews with three employees involved in the case...........................................................................110

5.1 Introduction............................................................................................................1105.2 Observation of a disciplinary hearing..................................................................110

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5.2.1 Disciplinary hearing...........................................................................................1105.2.1.1 Employee under investigation.................................................................................1115.2.1.2 Clinical team and environment................................................................................1135.2.1.3 Outcome of the hearing...........................................................................................113

5.3 Interviews................................................................................................................1145.3.1 Interview with Sam, the witness........................................................................114

5.3.1.1 Uncovering poor clinical practice in the team..........................................................1155.3.1.1.1 Poor clinical practice and conduct....................................................................1155.3.1.1.2 Managers ‘turning a blind eye’..........................................................................1155.3.1.1.3 Déjà vu.............................................................................................................1165.3.1.1.4 Collective responsibility....................................................................................116

5.3.1.2 Managing a poor-functioning clinical team..............................................................1175.3.1.2.1 Why had previous managers not stayed?........................................................1175.3.1.2.2 Ethnic composition of the team.........................................................................1175.3.1.2.3 Joyce returning to the team..............................................................................1175.3.1.2.4 Poor uptake of clinical supervision...................................................................1175.3.1.2.5 Sam’s perceptions of how the team viewed him...............................................118

5.3.1.3 Impact of dealing with poor conduct and practice on Sam......................................1185.3.1.3.1 Professional and personal toll...........................................................................1185.3.1.3.2 Support to manage the clinical team................................................................119

5.3.1.4 Patient group treated...............................................................................................1195.3.2 Interview with Paul, the chairperson..................................................................120

5.3.2.1 Uncertain future of the Trust....................................................................................1205.3.2.2 Unveiling poor conduct and practice leading to disciplinary action..........................121

5.3.2.2.1 Ethnicity is not an issue....................................................................................1225.3.2.2.2 Grievance taken out.........................................................................................1225.3.2.2.3 Managing the consequences from disciplinaries..............................................1235.3.2.2.4 Inconspicuous discussions on disciplinaries.....................................................123

5.3.2.3 Quality of staff supervision and support...................................................................1235.3.2.3.1 Lack of meaning of appraisals..........................................................................1245.3.2.3.2 Lack of supervision and support as mitigating circumstances..........................124

5.3.2.4 Undertaking the role of chair...................................................................................1255.3.2.4.1 Consequences of lack of training in making decisions on the outcome............1255.3.2.4.2 Maintaining impartiality and fairness.................................................................1265.3.2.4.3 Maintaining impartiality and transparency........................................................126

5.3.3 Interview with Monica, the BME HR manager...................................................1265.3.3.1 Disaggregation and reconfiguration of services.......................................................127

5.3.3.1.1 Impact on clinical staff......................................................................................1275.3.3.1.2 Changes in team managers..............................................................................1285.3.3.1.3 Why do some areas in the Trust have less disciplinaries than others?............128

5.3.3.2 Training and experience of the chair.......................................................................1285.3.3.2.1 Absence of E&D training..................................................................................1295.3.3.2.2 Perceptions of the chair of the panel................................................................1295.3.3.2.3 Quality of decision-making...............................................................................129

5.3.3.3 Consequences of increased administration.............................................................1305.3.3.3.1 Withdrawal of administrative support................................................................1305.3.3.3.2 Loss of strategic planning to minimise disciplinaries........................................1305.3.3.3.3 Lack of preparatory work with managers..........................................................1315.3.3.3.4 Lack of preparatory work with staff under investigation....................................131

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5.3.3.3.5 Lack of preparatory work to reintegrate the employee into the team................1315.3.3.4 Maintaining impartiality and adhering to the facts of the case.................................132

5.3.3.4.1 Observations of IOs presenting their case........................................................1325.3.3.5 Key themes emerging from disciplinaries................................................................133

5.3.3.5.1 Disparity between outcomes for white and BME staff.......................................1335.3.3.5.2 Difference in articulation...................................................................................1345.3.3.5.3 Disproportional representation of BME staff in the disciplinary process...........1345.3.3.5.4 Perceptions of the HR department...................................................................135

5.4 Summary.................................................................................................................135

Chapter 6: Findings from participant observations and interviews with employees involved in the disciplinary process in the Trust............................136

6.1 Introduction............................................................................................................1366.2 The context of the Trust........................................................................................137

6.2.1 The pressure to secure Foundation Trust (FT) status.......................................1376.2.2 Reconfiguration of services...............................................................................1376.2.3 Recruitment of BME staff...................................................................................1416.2.4 Perceptions of the Trust E&D initiatives............................................................1426.2.5 Perceptions towards the study..........................................................................1446.2.6 Observations of behaviours...............................................................................147

6.3 Perceptions of BME employees in the Trust.......................................................1476.3.1 Links to the historical, societal, political and personal context..........................1476.3.2 Senior managers perception of BME employees particularly black African nurses

...........................................................................................................................1516.3.3 Senior managers perceptions of relationships and tension within BME employees

1536.3.4 Perceptions of BME staff commitment and lack of trust placed on them..........1546.3.5 Perceptions of BME employees treated unfairly................................................1576.3.6 Playing the ‘race card’.......................................................................................1596.3.7 Perceptions of cultural differences in working practices....................................159

6.4 Perceptions of the disciplinary process..............................................................1626.4.1 Perceptions of managers dealing with BME staff..............................................1626.4.2 Underuse of capability procedures....................................................................1656.4.3 Suspension of staff............................................................................................1666.4.4 Perceptions around the descriptive statistics....................................................1686.4.5 Perceptions of the phenomenon investigated...................................................170

6.5 Perceptions of employees directly involved in the disciplinary process.........1706.5.1 Role of an IO......................................................................................................1716.5.2 Lack of training to undertake the role of chair...................................................1726.5.3 Diminished administrative support.....................................................................1736.5.4 Conducting investigations..................................................................................1736.5.5 Relationships between the investigating team and investigated employees.....1776.5.6 The disciplinary panel........................................................................................1786.5.7 Role of the professional lead.............................................................................1806.5.8 Perceptions of TU representation......................................................................1826.5.9 The employee under investigation.....................................................................1846.5.10 Mitigating circumstances.................................................................................185

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6.5.11 Reactions to disciplinary outcomes.................................................................1886.6 Conclusion..............................................................................................................191

Table 1: Summary of the key themes............................................................................192

Chapter 7: Discussion...........................................................................................1937.1 Introduction............................................................................................................1937.2 Discussions of the findings..................................................................................1907.3 The Trust.................................................................................................................191

7.3.1 Leadership in the Trust......................................................................................1917.3.2 The impact of disaggregation and reconfiguration on services and staff..........1937.3.3 Management in the Trust..................................................................................1957.3.4 Changes to organisation culture.......................................................................1977.3.5 Patient care........................................................................................................1987.3.6 Breakdown in staff supportive structures...........................................................200

7.4 BME employees in the Trust.................................................................................2017.4.1 Recruitment of BME staff...................................................................................2027.4.2 Socialisation and working practices of BME staff..............................................2037.4.3 BME staff treated with suspicion and distrust....................................................2057.4.4 Impact on BME staff..........................................................................................2077.4.5 The 'Black African'.............................................................................................2087.4.6 Discrimination and racism within and between employees...............................209

7.5 Disciplinaries in the Trust.....................................................................................2107.5.1 Descriptive statistical data on disciplinaries......................................................2117.5.2 The wider context: outside the NHS..................................................................2137.5.3 Capability procedures........................................................................................2137.5.4 Reactions to the phenomenon investigated......................................................2147.5.5 Equality and diversity.........................................................................................2167.5.6 Disciplinary hearings and investigations............................................................2177.5.7 Disciplinary outcomes........................................................................................221

7.6 Summary.................................................................................................................224

Chapter 8: Conclusion..........................................................................................2218.1 Introduction............................................................................................................2258.2 How does this study advance research in the field?..........................................225

8.2.1 Implications of this study for policy and clinical practice....................................2278.3 Study limitations....................................................................................................2308.4 Dissemination of the findings...............................................................................2338.5 Summary.................................................................................................................234

References.............................................................................................................236

Appendices............................................................................................................254Appendix 1: The disciplinary procedures examined in this study.............................256Appendix 2: Recruitment letters....................................................................................259Appendix 3: Participant information sheets.................................................................261Appendix 4: Consent forms...........................................................................................273

Chapter 9: Overview of the integration of knowledge, research and practice.2779.1 Introduction............................................................................................................277

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9.2 Development of self...............................................................................................2779.3 Advanced research methods................................................................................2789.4 Service evaluation..................................................................................................2799.5 Leadership in healthcare organisation................................................................2809.6 Emotional intelligence...........................................................................................2809.7 Policy, politics and power.....................................................................................2819.8 Dissemination of the findings...............................................................................2829.9 Conclusion..............................................................................................................283

Chapter 10: Research log.....................................................................................28410.1 Introduction..........................................................................................................28410.2 Why I took a taught clinical doctorate programme and not a PhD route?.....28410.3 Selecting the subject to investigate...................................................................28510.4 Framework, tools and skills needed to undertake the study...........................285

10.4.1 Gaining access to a Trust................................................................................28710.5 Research process................................................................................................28810.6 Academic supervisors.........................................................................................29010.7 Peer support.........................................................................................................29010.8 Conclusion............................................................................................................291

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Abstract

Aim: This study was undertaken to explore the over-representation of black and minority ethnic (BME) staff in the disciplinary process in a National Health Service (NHS) Mental Health Trust.

Background: The Trust where this study was undertaken recognised there was a disproportional representation of BME staff involved in the disciplinary process. No reasons were given by the Trust for why this phenomenon existed. The over-representation of individuals from BME groups in NHS disciplinary hearings was raised as a topic for investigation by Parliament in 2008. Seminal work by Archibong and Darr (2010) has explored reasons for this over-representation. Ethnographic methodologies have not been used previously to develop our understanding of this area.

Methods: Critical and focused ethnography were used to observe a disciplinary hearing and gain the perspectives of employees directly involved in the disciplinary process in a single trust. To examine the culture of the Trust, data were collected through fieldwork, participant observation, semi-structured interviews, journal/diary and secondary data. Thematic analysis devised by Braun and Clarke (2006) was used to analyse the data collected.

Findings: Negative perceptions towards BME staff, particularly ‘black African’ nurses and healthcare assistants were uncovered. Tensions and rivalries within and between BME staff were also found.

Disciplinary investigations were not always based on facts and not all the findings were presented. Investigating officers and the chair of the panel were not always given training to undertake their roles. In some cases, BME personnel were intentionally selected onto the disciplinary panel to avoid accusations of racism, particularly when BME employees were likely to be dismissed. Disparity of the sanctions imposed for similar cases were reported. There was a perception that BME staff were not articulate and treated more harshly than their white counterparts. Equality and diversity initiatives also remain on the periphery.

The disaggregation and reconfiguration of services had some bearing on the performance of staff. Line management and clinical supervision was underutilised. Some managers who confronted BME employees were accused of ‘racism’ and had grievances taken out against them.

Conclusion: Disciplinary processes involving BME staff cannot be discussed in isolation. Key factors, such as the impact of disaggregation and the reconfiguration of the Trust at a time of continuous change in the NHS, the employment of BME staff as well as the disciplinary process itself, need to be considered together. The discussion also needs to shift from the polarised division between ‘black and white’ staff and focus on the differences and tensions within and among BME staff.

8

Acknowledgements

First and foremost, I thank the Trust, which allowed me to undertake this study, and

all the participants who have contributed. I am grateful for the support given to me by

my supervisors, Professor Helen Cowie and Dr Debbie Cooke, and thank them for

their comments and guidance. I am also thankful for the support and understanding

from Dr Iris Gault. A special thank you also goes to: Roger Palmer, Satwant Lahoria,

Karen Stobart, Dr Earl Hopper, Dave and John Sandhu. Finally, with heartfelt love I

thank my partner Tracy Knight for being with me throughout this journey. Tracy, I look

forward to reacquainting myself with you and cannot wait to do all those jobs you

have lined up for me.

I dedicate my doctorate to my parents, Surinder Kaur and Ajit Singh Sehmi, whose

spirit lies within me, and my siblings Nani, Shanti, Pam and Vindy.

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Acronyms

Acas – Advisory, Conciliation and Arbitration Service

AHP – Allied health professional

BAME – Black, Asian and minority ethnic

BME – Black and minority ethnic

CHI – Commission for Health Improvements

CPA – Care Programme Approach

CQC – Care Quality Commission

DoH – Department of Health

DRE – Delivering Race Equality

E&D – Equality and Diversity

FT – Foundation Trust

FtP – Fitness to Practise

GMC – General Medical Council

GP – General practitioner

HCA – Healthcare assistant

HR – Human resources

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IO – Investigating officer

NAO – National Audit Office

NCAS – National Clinical Assessment Service

NHS – National Health Service

NMC – Nursing and Midwifery Council

NNRU – National Nursing Research Unit

NRES – National Research Ethics Service

PADR – Performance Appraisal Development Review

RCM – Royal College of Midwives

RCN – Royal College of Nursing

R&D – Research and Development

RES – Race Equality Scheme

SSI – Site Specific Information

SUI – Serious Untoward Incident

TU – Trade Union

TUC – Trades Union Congress

UREC – University Research Ethics Committee

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Chapter 1: Introduction

1.1 Introduction

This chapter provides a brief background about the National Health Service (NHS),

black and minority ethnic (BME) staff and disciplinaries. It also describes the

structural overview for this study.

1.2 The NHS

Funded by the taxpayer, the NHS came into existence on 5 July 1948 (Gorsky,

2008). Since its creation, numerous management and structural reforms have taken

place. These have been in response to dealing with rising costs (as a result of new

medical procedures and drug treatments), an ageing population and greater public

expectations. To meet these demands, competition has been introduced into the

NHS by incorporating the independent and voluntary sector in providing services

(Gorsky, 2008). With limited funding and resources, recent governments have

concentrated on improving efficiency, cost-effectiveness and productivity in order to

meet the needs of service users (Doherty, 2009). High-quality care and standards

are emphasised through meeting performance indicators and clinical outcomes set

by the Department of Health (DoH) (Buchan and Seccombe, 2013).

To undertake the tasks of the NHS, the government relies on staff to deliver its

programme. There is much public sentiment about preserving the values of the NHS,

as observed by politicians from the main political parties. However, since its

inception, Labour and Conservative governments have had problems recruiting NHS

staff (particularly in nursing) from the United Kingdom. Over time, part of the

reluctance of the indigenous population to work in the NHS has been due to the 12

dwindling status, low pay and poor working conditions (Hart, 2004). In addition to

these factors, the stressful nature of the job has also contributed to the attrition of

qualified nurses (Doherty, 2009). To meet the shortfall of nurses and doctors at

various times of depletion and crisis, governments of either political party have relied

on their former colonies.

1.2.1 BME employees

Today the NHS is the biggest UK employer and the principal employer of BME staff

in England (Healy and Oikelome, 2006; Siva, 2009). Since its inception, BME

employees from the indigenous population or abroad have featured as part of the

NHS. However, their experiences and contributions have not always been positive.

For example, from a historical perspective, BME doctors and nurses were recruited

and appointed in less sought-after roles and particular areas of care such as

psychiatry, working with the chronically sick and elderly. Student nurses from the

Commonwealth, particularly the Caribbean, were discriminated against and forced to

undertake pupil nurse training to become state enrolled nurses. Questions were

raised about the motivation, racial characteristics and intellectual capacity of

Caribbean people who wanted to train as state registered nurses (Trant and Usher,

2010).

The experience of discrimination and ill treatment of first-generation nurses from

colonial countries has put off the second generation from following in their footsteps.

Consequently, governments have had to rely and depend on recruiting from abroad.

A mixed reaction prevails. On one side, for the government of the day, overseas

nurses have provided a constant supply of cheap labour to meet the shortage of

staff. Governments have used them to control public sector wage demands. On the

13

other side, overseas and BME employees perceive themselves as being

undervalued, treated unfairly and marginalised.

Governments have introduced legislation and policy initiatives to tackle the disparity

and discrimination around the experiences of BME people. However, huge doubt

remains about the lack of commitment by NHS Trusts and the effectiveness of these

schemes (Ali et al., 2013).

Simpson et al. (2010) stated how the positive contribution of migrants in the history

and shaping of the NHS has been denied. Migrants and BME staff in the NHS have

focused on their lack of opportunities: BME nurses are over-represented at lower

grades and under-represented in senior and leadership positions (Ashraf, 2013);

there is a lack of recognition of the skills and experiences of BME nurses, particularly

those from overseas (Allen and Larsen, 2003); the experience of racism, harassment

and discrimination is widely reported. Some of this behaviour is from patients and

carers. Sprinks (2008) reported that older people were more likely to be racist. Some

patients do not want to be nursed by staff of a particular ethnicity and this is accepted

by some health services (Jönson, 2007); BME applicants shortlisted for jobs are less

likely to be appointed than white applicants (Kline, 2013); qualified overseas nurses

have been appointed as healthcare assistants (HCAs) (Nichols and Campbell, 2010);

BME employees face disciplinary or grievance proceedings more than their white

counterparts (Archibong and Darr, 2010; Archibong et al., 2013); disproportionate

BME registrants have been referred to the Nursing and Midwifery Council (NMC).

Disciplinaries involving BME employees will be looked at more closely in this study.

14

1.2.2 Disciplinaries

When employees have continually been unable to perform their tasks and persistent

issues have arisen and been breached, disciplinary action is legitimate to manage

the situation. Disciplinaries have been used to reinforce standards of performance,

minimise improper conduct and correct employee behaviour. Disciplining staff should

be used as a final option. The aim of discipline is to improve employee conduct, not

to punish and humiliate the employee. Disciplinary issues in the workplace can

usually be resolved informally. However, if unsuccessful, a formal route is taken. The

use and application of disciplinary procedures in the NHS follow a process that is

stipulated in a disciplinary policy for each NHS Trust. For this study, the stages of

disciplinary procedures and the role of employees involved in the process are

identified and discussed in Appendix 1. The process and procedures are there to

reinforce fairness, transparency and the rights of the employee regardless of their

race, colour, ethnicity, sexual orientation and gender. The policy around disciplinary

procedures complies with the Advisory, Conciliation and Arbitration Service (Acas)

Code of Practice on Discipline and Grievance (Acas, 2009).

The work of Beishon et al. (1995), Carter (2000) and Archibong and Darr (2010)

highlighted that BME healthcare professionals are twice as likely to be disciplined in

comparison to their white counterparts in the NHS. This study will explore the

phenomenon of the disproportional representation of BME employees in an NHS

Trust.

15

1.3 Overview of the study

1.3.1 Literature review

Current literature retrieved on the over-representation of BME employees involved in

the disciplinary process will be reviewed in chapter 2. This will provide a context of

the gaps that currently exist and also a rationale for undertaking this study.

1.3.2 Methodology

Ethnography as a qualitative approach has been used for this study. Justification for

this approach and the characteristics of ethnography adopted to meet the aims will

be outlined in chapter 3.

1.3.3 Findings

Descriptive statistics related to disciplinaries from the Trust under investigation will be

introduced in chapter 4. Findings from an observation of a disciplinary hearing, and

interviews with three employees involved in the case, will be presented in chapter 5.

Chapter 6 will pay attention to the findings from interviews with employees involved in

other disciplinary cases in the Trust. A summary of the findings from chapters 4 to 6

will be given in chapter 7.

1.3.4 Discussion

Discussion of the findings will also be presented in chapter 7. These findings will be

discussed and linked to existing literature on the subject being investigated. The

study limitations will also be discussed. Finally, recommendations to inform the

practice around disciplinaries involving BME staff will be provided.

16

1.4 Summary

A brief background and context to the study have been provided in this opening

chapter. An outline of the structure of this thesis has also been given.

17

Chapter 2: Literature review

2.1 Introduction

In this chapter, an overview of the current literature retrieved on the disproportional

representation of BME staff involved in the disciplinary process in the NHS is

reviewed. Five themes are explored. This background information not only provides a

context of the gaps that currently exist but also supports the reasons for undertaking

this study.

2.2 Accessing the literature

University learning resource centres and a medical school library attached to a

teaching hospital were used to, access the computers, healthcare databases,

download articles, photocopy articles from journals and borrow books. To access the

databases, NHS Athens registration was needed and obtained. Further help during

the literature search was obtained from the staff in these settings.

The literature retrieved was sourced from journal articles, reports, government

circulars, conference proceedings, grey literature and references within relevant

articles.

2.3 Search strategy

To limit the number of searches, the literature needed to be in English, UK based and

available as full texts.

2.3.1 Database searching

OvidSP, a specialist search tool was used. In addition to allowing access to Medline,

OvidSP allowed access to Embase, Health Management Information Consortium, 18

Maternity and Infant Care and PsycINFO. Databases on the EBSCOhost search

platform allowed access to AMED and CINAHL.

Other databases accessed were the British Nursing Index and Cochrane. As there

was limited literature available, the librarian helpfully directed me to the Health

Business Elite and Social Care Online databases.

2.4 Results from the literature search

In 2008, the South East Coast BME Network published its Race Equality Service

Review. Although 15% of staff came from BME groups, 25% of BME employees

were involved in the disciplinary process. This concern was raised in the House of

Commons (Hansard, 2008). Lord Darzi, responding for the government, reported that

the NHS Institute for Innovation and Improvement was commissioning a study to

investigate this serious matter.

As a result, a seminal research study looking at The Involvement of Black and

Minority Ethnic Staff in NHS Disciplinary Proceedings was undertaken by Archibong

and Darr (2010). Aspects of this significant study are incorporated into the themes

below. Its limitations are discussed at the end of this chapter, as the gaps identified

have contributed to the title and nature of this research study.

Relevant papers that have been retrieved from the literature search will be reviewed

under five themes. Owing to the complexity of the subject, there will be some content

that will overlap between themes:

2.4.1 Disciplinaries outside the NHS;

2.4.2 Poor performance, suspensions and disciplinaries in the NHS;

19

2.4.3 Presentation of BME staff;

2.4.4 Organisation and management culture of the NHS;

2.4.5 Equality and Diversity (E&D) agenda.

These five themes have been selected as they have been directly and indirectly

conspicuous around the subject related to the disproportional representation of BME

staff involved in the disciplinary process.

2.4.1 Disciplinaries outside the NHS

This section presents the international picture and touches on disciplinaries in

English-speaking westernised countries. It includes disciplinaries in other public and

private organisations, outside the NHS, in the UK.

Although the literature review concentrated on disciplinaries in the UK, international

studies from the USA and Australia were found in the search. These articles present

a mixed depiction of the inclusion of BME nurses in the studies. For example, a study

by the National Council of State Boards of Nursing (2009) found a slightly higher

percentage of African-American, Native American and Hispanic nurses were

disciplined in comparison to the general nurse population. In a study of the incidence

of disciplinary action towards advanced practice registered nurses, Hudspeth (2007)

did not state the race and ethnicity of the nurses. He also excluded race and ethnicity

when examining the discipline of nurse practitioners by boards of nursing in the USA

(Hudspeth, 2009). Pugh (2009) examined the unprofessional conduct of nurses, but

did not mention the ethnicity of the 21 Australian nurses interviewed. Both Hudspeth

and Pugh did not recognise that the race and ethnicity of nurses may influence the

likelihood of receiving disciplinary action. These findings should be considered with 20

caution as a comprehensive literature review in English-speaking westernised

countries is needed. This would determine the scale of BME nurses disciplined in

comparison with their white counterparts internationally.

Using evidence from monitoring carried out under the Race Relations Amendment

Act, 2000, the Trades Union Congress (TUC) report of the Black Workers

Conference (TUC, 2009) stated that black workers continued to be over-represented

in disciplinary action. However, the report did not indicate which sectors were

monitored. It is unclear if this disproportional representation is in the private and/or

public sector.

Archibong and Darr (2010) undertook a literature review to compare the disciplinaries

of BME staff in the NHS to those in other public sector organisations. In their study,

they examined the disciplinary process involving BME staff in the police service,

Transport for London, local government, central government and higher education.

Their findings for the police service and local government are similar to the

experience of BME employees in the NHS: managers quickly formalise the

disciplinary process; discriminatory attitudes prevail; ambiguity around disciplinary

policies exists; staff lack training. Harrow Council reported BME employees were

disproportionally affected by its disciplinary procedures at investigation/hearing

stages and by the sanctions imposed (Harrow Council Consultative Forum, 2007). In

terms of monitoring disciplinary proceedings, only a quarter of higher education

institutions observe this practice (Archibong et al., 2013). In its literature review into

the experiences of BME staff working in higher education, the Equality Challenge

Unit (2009) reported disproportionate levels of scrutiny of BME staff in comparison

with their white counterparts. Using data from the Home Office (2008), Archibong and

21

Darr (2010) also showed the Home Office was not analysing data on disciplinaries to

the optimal level.

Other studies have also examined the police force. Smith et al. (2012) found: Asian

police officers in the West Midlands police force were twice as likely to be subjected

to misconduct investigation as white officers; black police officers and staff with

Greater Manchester police were more than two times likely to be investigated for

misconduct than their white counterparts. Hagger Johnson et al. (2013) found ethnic

disproportionality in internal misconduct proceedings in the West Midlands police

force, Greater Manchester police force and the British Transport police.

Solicitors have also been investigated. Building on the work of Ousely (2008) and

Kandola (2010), John (2014) reported disproportional regulatory outcomes for BME

solicitors. John’s (2014) study revealed BME solicitors were subjected to severe

sanctions in comparison to white solicitors.

These studies show that disproportional representation of BME employees involved

in the disciplinary process is also found outside the NHS. Archibong and Darr (2010)

identified benchmarks and began to make comparisons between the NHS and

bodies outside the NHS. The rest of this study will now focus on disciplinaries in the

NHS.

2.4.2 Poor performance, suspensions and disciplinaries in the NHS

Analysing data obtained from NHS Trusts on disciplinaries, Archibong and Darr

(2010) found BME employees were almost twice as likely to be disciplined as their

white counterparts. They also found BME staff over-represented in the disciplinary

process were mainly employed in primary care, mental health and learning

22

disabilities. The scale of the problem and the number of staff disciplined nationally

are unclear as the data recorded by NHS Trusts is inconsistent (Archibong and Darr,

2010) and there is no centralised body collecting this information (Traynor et al.,

2013).

King and Wilcox (2003) and Archibong and Darr (2010) acknowledged the reasons

given for disciplinary action being necessary. An undisciplined workforce can impact

on low morale and poor levels of outcomes (King and Wilcox, 2003). Consequently

managers take disciplinary action (usually as a last resort) to change and correct the

behaviour and attitude of the individual not performing to the expected professional

standards. However, some managers do not use disciplinary measures as the last

resort (Archibong and Darr, 2010; Cooke, 2006a). After examining formal disciplinary

records and interviewing management and trade union (TU) officials, King and

Wilcox (2003) highlighted the difficulty managers have with the task of imposing

disciplinary action. This is as a result of: disciplinary guidelines and policies being

unclear; managers lacking skills and fearing the reaction from the person being

disciplined; the manager imposing the disciplinary action not receiving support from

their own manager; some inexperienced managers ignoring the issue and only

reacting when there is no choice after the issue has escalated to a crisis situation.

King and Wilcox’s (2003) study did not look at specific groups of the workforce and

was oriented towards employee-proposed discipline.

Archibong and Darr (2010) showed that line managers found it difficult to manage

disciplinary issues, and disciplinary policies were inconsistently applied. Managers

also lacked confidence in instigating informal strategies of the disciplinary process

with BME staff. It was perceived that BME employees were more likely to be

23

disciplined over insignificant matters, and BME staff felt that they were treated

harshly and unjustly by human resources (HR) managers. Managers were also

erroneously using disciplinary procedures to deal with performance issues. Further

perceptions arose of managers not being provided with the necessary skills to deal

with a diverse workforce and handle conflict situations effectively. Finally, Archibong

and Darr (2010) found that there was a lack of clarity between disciplinary, capability

and performance issues.

A review of how poor performance in nursing and midwifery is managed in the NHS

has been undertaken by the National Nursing Research Unit (NNRU, 2010).

Evaluation of the definition of poor performance by the National Clinical Assessment

Service (NCAS) as: “any aspects of practitioner’s performance or conduct which:

pose a threat or potential threat to patient safety; expose services to financial or other

substantial risk; undermine the repetition or efficiency of services in some significant

way; are outside acceptable practice guidelines and standards” (NCAS, 2010, p.2) is

used and challenged by the NNRU. It reported the robustness and application of this

definition was neither assessed nor tested. On closer examination of this review

study, it is unclear why the NNRU uses a definition from a document relevant to

doctors, pharmacists and dentists, and applies it to nurses. The NNRU does not give

its rationale for doing so.

In addition to 68 studies reviewed from 1998 onwards, the NNRU obtained further

evidence by analysing reports from NMC hearings and observations of an NMC

Fitness to Practise (FtP) hearing. Nationally, it is difficult to find out how many nurses

are ‘poorly performing’ as NHS Trusts are not required to report cases of

suspensions to the DoH. Again, this highlights that there is no centralised body

24

collecting national data on suspensions. The NNRU also found that suspensions

resulting from actual and potential threats to the safety of patients were uncommon.

The biggest reason for referral to the NCAS was not complaints made by patients but

complaints made by clinicians against ‘poor-performing’ colleagues.

In terms of the management of poor performance in nursing and midwifery, the

NNRU found the quality and rigour of initial investigations varied. Local procedures

were open to interpretation and extensive inconsistency. The suspension of nurses,

when patient safety was not compromised, was a common practice. Managers often

used suspension as their first choice. Approaches to addressing poor performance

were perceived as punitive. Nurses did not always know the reasons for their

exclusion. Finally, clinicians who reported poor-performing colleagues did not always

know the outcomes of their referral.

Stone et al. (2011) undertook a literature review, collected data from the NMC and

observed NMC FtP hearings on how poorly managed nurses and midwives were

handled in the NHS. Their overall significant findings were an absence of recorded

data on suspensions of NHS staff and the non-existence of systematic research into

this area.

Reviewing the National Audit Office (NAO, 2003) report, Stone et al. (2011) found

nurses and midwives made up 53% of the total suspensions in the NHS from April

2001 to July 2002. This emphasised that nurses were more likely to be suspended

than doctors. The decision to suspend nurses was not always as a result of patient

safety being compromised but automatic reactions by managers without undertaking

an adequate initial investigation. They found the DoH guidance on suspension of

25

nurses was perceived as confusing; the interpretation and application of the guidance

was open to abuse by managers and the management of suspension was

inconsistent and poorly conducted.

Stone et al. (2011) also reviewed the study by Murray (2005) on the experiences of

nurses suspended in the workplace. They observed that most nurses returned to

work after being suspended; the suspension varied between two weeks and six

months; again there was an inconsistent approach to the use of suspension; some

nurses were suspended without being informed of the nature of allegations from the

preliminary investigation; the probability of suspensions increased for nurses who

were aged over 40 and/or male and/or from BME groups.

Attempts have been made to calculate the costs of suspensions in the NHS. Using

information from the NAO (2003) report and the recorded number of nurses

suspended during 2002, Murray (2005) estimated that it cost the NHS £4.5m. The

findings of Roper (2006) estimated that it cost the NHS up to £100m to suspend 375

nurses, 152 doctors and 35 other clinical staff. The academic rigour of Roper’s

findings needs to be treated with caution as Roper was working for the Daily Mirror

and obtained this information under the Freedom of Information Act 2000. In another

study, Kmietowicz (2005) found that delaying disciplinary cases cost the NHS £40m.

The formal suspension of healthcare staff in law is considered to be ‘a neutral act’

(NAO, 2003). This is not always the case, particularly the impact on the well-being of

the suspended person. The effect of suspensions has been included by Murray

(2005) in his study. Using data from the Royal College of Nursing (RCN) counselling

service, Murray (2005) discussed the acute and chronic emotional responses of

26

shock, anxiety, anger and distress experienced by nurses who have been

suspended. Nurses barred from going into work and contacting colleagues suffered

from a post-traumatic reaction, adjustment to loss and threat to identity. Murray

(2005) used the Clinical Outcome Routine Evaluation system and analysis of

individual interviews to arrive at these findings. Reiterating Fagan’s (2004) findings,

Stone et al. (2011) described the negative impact of suspension in terms of personal

and professional costs. Alleyne (2004) found a large proportion of the participants in

her study reported considerable negative effects to their emotional and physical well-

being.

In their conclusion, Stone et al. (2011) highlighted the lack of empirical data available

and inadequate recording of information on poor performance. The role of support,

mentoring and remediation for nurses performing poorly was inconsistent and varied.

To minimise the high quantity of disciplinary action and increased costs of disciplining

staff, Stone et al. (2011) drew on the work of Cooke (2006a) into the use of quasi-

formal discipline by some managers. Cooke’s (2006a) study is also reviewed

separately.

Using the data collected from in-depth interviews with managers, nurses and TU

representatives, Cooke (2006a) presented a model of discipline used by some

managers. A quasi-formal discipline in some cases was employed instead of

implementing the formal disciplinary procedures set in place to punish nurses. This

method was used with ‘problem nurses’ who could not be disciplined formally.

Nurses who underwent quasi-formal disciplinaries felt that they were being singled

out and bullied. This form of disciplinary action was not reported at Trust Board

meetings and was hidden from its executives.

27

Examining the decisions to discipline nurses formally, Cooke (2006a) found: HR

personnel felt managers decided themselves to initiate disciplinary action without

contacting HR at the early stages of the investigation and only contacted them when

they found themselves in difficulty; TU representatives perceived disciplinary action

was excessively used by insecure and inexperienced managers; managers felt

disciplinary action would improve performance and used it when the nurse being

investigated failed to show remorse; the decision to discipline nurses in some cases

was based on the instincts of the manager rather than collecting the actual evidence

related to the issue.

Scrutinising the conduct of disciplinary cases, Cooke (2006a) also reported that it

varied. Managers again considered that disciplinary action would correct behaviour to

a professional standard; TU representatives countered that the investigations were

carried out in a hostile environment and often mishandled; both nurses and TU

representatives reported that managers lacked professional integrity.

Finally, Cooke (2006a) noted that those nurses who were taken to disciplinary

hearings, and as a consequence resigned or were sacked, often went on to work in

nursing homes. Thus, the issue of public safeguarding, poor performance and

transgression moved into the independent sector.

Professional regulatory bodies involved in the disciplinary process have been

scrutinised by the DoH because of their lack of stringency, conduct and transparency

of process in dealing with incompetent and deviant professionals on their registers

(Cooke, 2006a). Regulatory bodies interviewed in the study by Archibong and Darr

28

(2010) reported that the disciplinary panels were composed of white, middle-class

males and did not represent the diversity of the workforce.

Archibong and Darr (2010) also found: BME staff subject to disciplinary action did not

know where and how to access support; overseas-trained staff felt isolated; TU

representation was not always sensitive to the needs of BME staff; perceptions of

discrimination experienced by BME staff going through disciplinary action were

minimised.

During the literature search, several anecdotal reports in various healthcare-related

journals around disciplinary processes involving BME staff have been found.

However, these findings have not been included because of their lack of academic

rigour and also their journalistic quality.

2.4.3 Presentation of BME staff

To begin this section, the work carried out by the NHS North West (2008) is

introduced. Its work included an exhibition, a booklet and a short film on the history,

experiences and contributions of BME people in the establishment and running of the

NHS since 1948. It also referred to the prejudice and racism experienced by Mary

Seacole, when she offered to look after sick and wounded soldiers on the front line

during the Crimean war and nursing agencies declined her services. The NHS North

West (2008) highlighted that Florence Nightingale refused to interview Mary Seacole.

Black migrants who wanted to become nurses discussed their frustrations of being

offered and forced to undertake the two-year pupil nurse training instead of the three-

year student nurse programme, as they were not perceived good enough. Those who

protested were threatened with being sent back to their homeland. General

29

practitioners discussed their limited opportunities and being restricted to working in

poor inner city areas of the UK. Interviews with senior clinicians and managers

counteracted the anecdotal claims that migrant workers were to blame for the

performance of the NHS.

The strength of the material produced by the NHS North West (2008) provided a

context and an overview of the chronological significant events and landmarks.

Various clinicians from different bandings/grades, ethnic backgrounds, gender and

professions shared their negative and positive experiences around diversity and

equality. Although its material is not an actual study, it has been included as it

provides a brief historical synopsis and starting point.

2.4.3.1 Terminology

Madison (2004) stated the interpretation of how people were presented and

represented as holding power and meaning. The issue of how people and groups are

defined and presented in many of the articles tends to be overlooked or polarised

between simplistic categories of ‘black’ and ‘white’. Rarely are these categories

looked at, challenged and critically analysed. Allen (2006) argued that the politics of

description created differences; difference necessitated classification; categorisation

involved power. Drawing on the work of Hurtado (1996) and Myser (2003), Allen

(2006) emphasised:

“The power ‘we’ have as white persons to represent the other groups is not evenly

distributed. Most of it has been produced by and for white men even though white

women also benefit… Many scholars have argued that most conversations about

cultural ‘differences’ depend upon and reproduce a privilege white norm.” (p. 66)

30

When closely scrutinised and deconstructed, the term ‘white’ is seen as the hallmark

for the norm, power, knowledge, western civilisation and goodness (Allen, 2006). In

all the literature retrieved and reviewed, the term ‘white’ (when used): is not defined;

remains subtly in the background; continues to be the same; is depicted as neutral;

on the surface is depoliticised and perceived as the norm; is not questioned. The

issue of whiteness being at the centre and the mainstream is challenged and linked

to the historical colonial past and how this manifested in ‘institutional racism’, as

illustrated in the MacPherson Inquiry (1999).

Although there are no variations in the term ‘white’, a complex and confused account

is depicted in the language and labels used to describe the ‘non-white’, which is

weighted with various descriptions. For the ‘non-white’ person and groups, numerous

terms, such as ‘black’ (Alleyne, 2004), ‘minority ethnic groups’ (Healthcare

Commission, 2009), ‘overseas trained’ (Larsen et al., 2005), ‘internationally recruited’

(Pike and Ball, 2007), and ‘black and minority ethnic (BME)’ (Johns, 2005), are used

in the literature reviewed.

Without clarification, there is an assumption that the term ‘BME’ (applied to

individuals, staff or groups) has a standardised defined meaning. Consequently BME

employees are presented as one homogenised body. Alleyne (2005) outlined that

blacks were seen as ‘special’ cases and/or ‘victims’. Differences within ethnic groups

are denied as everyone is seen as the same. The key research on the

disproportional representation of BME staff involved in disciplinary procedures by

Archibong and Darr (2010) presented this problem. In their landmark study, who and

what BME employees were are not defined and are overlooked by the authors. Other

writers give a generalised account, as observed in Alleyne (2005) who wrote:

31

“…the use of the term black will refer to people with known African heritage.” (p. 298)

It is unclear to which heritage in the continent of Africa she is referring as there are

many to choose from. Some authors began to give a definition but then did not

expand on it. Obrey and Vydelingum (2004) stated:

“The term ‘black’ is a political category to describe people’s race, colour or ethnic

origins to differentiate them from the white population.” (p. 14)

Closer scrutiny of the terminology arouses discomfort, as shown in the research of

Dhaliwal and McKay (2008). They politicised and explicitly brought in emotive factors

into their definition:

“The term ‘black’ is used in this report to refer to non-white nurses of African,

Caribbean, South Asian, Chinese, South East Asian and South American descent to

connote their shared experience of colonialism, migration and racism.” (p. 3)

Research into specific ethnic and racial groups has been undertaken: Henry (2007

and 2008) looked at the experiences of Ghanaian nurses and midwives in the NHS;

Likupe and Archibong (2013) studied the experiences of black African nurses.

2.4.3.2 ‘Black and black’

The studies are simplified to a ‘black versus white’ issue and ignore the complexities

of the subject of race, ethnicity and culture within the NHS. BME employees are

presented as ‘oppressed’ and ‘victims’ while white staff as the ‘oppressors’ (Alleyne,

2004 and 2005).

The difference in progression and the tensions between different ethnic groups, as

well as the perception of inequalities between them, are not captured by current

32

monitoring processes (Healy and Oikelome, 2006). Rarely did studies and

government reports show the antagonism within ethnic and racial groups. Until

recently, this area has been overlooked, but now the problems that have appeared

within these groups have been exposed. Through semi-structured interviews, Henry

(2008) discussed how Ghanaian nurses and midwives perceived managers as

preferring African Caribbean nurses to black African ones and as a result promoting

them more quickly than black African nurses. In looking at the experiences of black

African nurses, Likupe and Archibong (2013) revealed the perceived racism among

and between overseas nurses. Black African nurses perceived nurses from the

Philippines as passive and compliant. Within the ‘white’ group, there was a

perception that East European nurses needed more reassurance and lacked the

initiative to assert their autonomy.

Finally, the subjects of race and ethnicity have been treated separately and are rarely

linked and associated to class and gender. The only studies retrieved from the

search that combined these issues are by Dhaliwal and McKay (2008) and Healy and

Oikelome (2006).

2.4.3.3 ‘Saviours’, ‘exploited’ and ‘exploiters’?

BME staff are presented as being ‘saviours’ of the NHS, ‘exploited’ by the NHS or

‘exploiters’ of the NHS. BME staff, particularly nurses, are portrayed as saviours for

governments especially when there has been a shortage of staff and problems

around recruitment (Obrey et al., 2007; Snow and Jones, 2011). Healy and Oikelome

(2006) argued that the NHS could not exist in its current form if overseas qualified

professionals and BME staff left it.

33

In contrast, Larsen et al. (2005) and Henry (2008) examined the perception that

overseas-trained nurses were exploited or only working for their own economic and

financial gains. Henry (2008) pointed out the complexities and context of the

motivations of Ghanaian nurses and midwives migrating to Britain, and what

happened to them when they got locked into a stagnated and despondent position.

Despite participants in the study ‘acting up’ into senior positions, they failed to secure

permanent positions after not passing their interviews. These participants felt

managers did not provide the necessary support to facilitate their career progression

and attributed discrimination to their stagnation. With little choice and poor promotion

prospects, some of these nurses focused their attention on monetary gains to extend

their property and financial investments when retiring and returning to their homeland

in Ghana.

Lewis (2011) reported how black nurses and HCAs were targeted by NHS anti-fraud

investigators; 66 out of the 98 prosecuted were African Caribbean; 59% of the cases

constituted around fraud or criminal offences related to false documents. Questions

are raised about the academic rigour and methods used to test the validity of Lewis’s

(2011) findings.

2.4.3.4 Overseas staff

The recent arrivals and experiences of overseas health professionals, particularly

nurses and doctors, have been explored in several studies (Allan et al., 2009; Healy

and Oikelome, 2006; Henry, 2007 and 2008; Hunt, 2007; Larsen et al., 2005; Larsen,

2007; Likupe, 2006; Obrey and Vydelingum, 2004; Oikelome, 2007; Pike and Ball,

2007).

34

Archibong and Darr (2010) found overseas-qualified clinicians, who had been trained

differently and were acquainted with different ways of working, were given insufficient

support to make the transition to adapt to the values and culture of the NHS. Hunt

(2007) stated that overseas BME nurses became alienated, devalued and

demoralised. He emphasised how their qualifications were denigrated as second

class and inferior as British nursing theory and clinical practice were idealised. In the

clinical area BME nurses were expected to integrate into the culture of the NHS. Hunt

(2007) discussed a sense of unfairness prevailing among overseas nurses who felt

that adjustments solely relied on them adapting. He argued that managers did not

consider how the culture of the NHS impacted on overseas-trained staff.

A phenomenological study by Obrey and Vydelingum (2004) found overseas nurses

were humiliated and embarrassed when their English was corrected in front of

patients and colleagues. This led to these nurses being alienated and left them

feeling isolated and disillusioned. Behaviour that was deemed as bullying could not

be challenged as they feared reprisal.

Allan et al. (2009) established discrimination in the form of racist bullying experienced

by overseas nurses. These findings arose out of three interviews and re-analysis of a

national study, undertaken by Smith et al. (2006), that recognised how racial

discrimination was experienced by overseas nurses at an interpersonal and

organisation level while working in UK healthcare settings. They found overt and

indirect discrimination.

Archibong and Darr (2010) identified overseas-qualified nursing employees working

in higher bandings as being disciplined after patient complaints. Saundry et al. (2008)

35

found BME employees were less aware of their employment rights than their white

counterparts. This restricted BME workers from challenging any disciplinary action

initiated against them.

2.4.3.5 Perceptions of behaviours and attitudes of BME staff

The perceptions of ward managers on the functioning, competence and

professionalism of BME nurses has been investigated. Carter’s (2000) study in a

Trust with a disproportional representation of BME nurses involved in the disciplinary

process revealed how some ward managers perceived BME staff as ‘troublemakers’

and so were reluctant to employ this group in their clinical areas. These managers

reinforced their Eurocentric attitude by deducing from the high number of ethnic

minority staff going through the disciplinary process that this was indisputable

evidence that they were difficult to manage.

Alleyne (2004) found that conflict experienced by black people arose from subtle

comments and behaviours aimed at their race and cultural identity. This took the form

of some white staff: failing to notice the presence of black employees; refusing to

make eye contact when appropriate; excluding black colleagues; using words like

aggressive, scary, angry, frightening, threatening, difficult and problematic when

describing black people.

BME nurses who cannot present themselves in the ‘white way’ or the mainstream

established ways are perceived negatively by white managers and colleagues. Johns

(2005) suggested that ‘fitting in’ was seen as more important than the ability of the

BME nurse and as a result the different skills, qualities and experiences of BME

workers were unrecognised. To have a rapport with managers, black nurses had to

36

‘speak the same language’ and socialise with them. However, their home and family

circumstances prevented this.

Two studies conducted by the RCN (Dhaliwal and McKay, 2008; Pike and Ball, 2007)

found many BME female nurses were single parents with dependent children. The

working hours and shift patterns in nursing made it incompatible with the home lives

of these mothers. Consequently, their work had to be based in community settings as

the working hours in other clinical areas were not compatible with their childcare

arrangements. Reduced income, having additional jobs to supplement the main

income and lack of career opportunities were reported by the participants in the study

(Dhaliwal and McKay, 2008) who were all black and female. Additional findings from

these two studies noted that BME nurses perceived they were closely monitored,

they had to work harder and their managers did not consider them to be capable of

achieving managerial and supervisory roles.

Archibong and Darr (2010) found that BME employees at lower positions were

perceived as not being committed and/or performing to the accepted standards of the

NHS. A literature review undertaken on the experiences of black African nurses by

Likupe (2006) found that they were employed in low-skill and low-paid work. Their

skills and training were undervalued and unrecognised. Questions were raised about

the authenticity of their qualifications.

Archibong and Darr (2010) noted how different styles of communication were

negatively interpreted by colleagues, managers and patients. In an earlier and

separate study, Nairn et al. (2004) examined the problem of cross-cultural

37

communication and misinterpretations around eye contact, time, attitudes towards

authority figures and group/individual dispositions.

2.4.4 Organisation and management culture of the NHS

As well as healthcare employees not performing to the standards required by their

professional regulatory bodies and Trusts, studies by Carter (2000), Cooke (2006a

and 2007) and Stone et al. (2011) suggested management styles and organisational

factors contributed to discrimination and poor standards.

Politicians from all sides have accused the NHS of being monolithic, inefficient and

unresponsive to patients’ needs. This has led to major structural reform. To reduce

costs, do more for less and increase efficiency, market styles of management have

been introduced and used in the NHS. Trusts employ a style of management

characterised by explicit standards and measurement of performance, competition

and private sector mode of management. Carter (2000) argued this ‘new public

management’ has reduced ethnic equality in the NHS, as managers have become

preoccupied with stringent control on finances and resources. Despite the duties

imposed by the Race Relations (Amendment) Act 2000, the E&D agenda has

become marginalised because managers have become preoccupied with economic

factors.

Carter’s (2000) research also revealed that some white ward managers became

resentful and hostile towards equal opportunities policies. From the questionnaires

and in-depth interviews, these managers disclosed feelings of equal opportunities

policies being ‘politically correct’, humiliating white people and treating Asians with

‘kid gloves’. As a consequence of these attitudes, clinical areas could become

38

segregated and racialised. There was an assumption that an ethnic diverse team

would threaten the efficient running of the ward as BME staff were perceived as

problematic. Carter (2000) argued:

“The increasing pressure as a result of new public management to exert more and

more control over the workforce has implications for any social group who are

regarded ‘difficult’ to manage.” (p. 79)

The style of management adopted has led to BME staff being indirectly discriminated

against and many managers being averse to employing BME nurses because of their

perceived difficulty in integrating with white staff. Rather than recruiting staff that are

perceived as being difficult to control and manage, anecdotal evidence suggests that

Filipino nurses are being employed as they are perceived as being passive,

submissive and easy to manage (Likupe and Archibong, 2013).

Overall, Carter’s (2000) study still holds value today, as other studies have

incorporated the significance of his work into their research and found similar findings

(Archibong and Darr, 2010). The research design of Carter’s study incorporated a

directorate of medicine and directorate of psychiatry. The response rate to the 1400

questionnaires sent out is very respectable. Data was collected from 1993 to 1997. It

is unclear how many participants were interviewed. The interviews included different

ethnic groups from different levels within the directorate.

Duffin (2003) reported that the lack of competency among BME staff might not be the

fault of the nurse and might well arise from: poor training and supervision; managers

offering minimal support to nurses struggling with certain practices; workplace

39

context having a profound effect on the nurse’s performance, particularly where there

was low morale, high turnover of staff and heavy workload.

Healy and Oikelome (2006) found discriminatory practices continued to be replicated

and rationalised in the workplace. They found that overseas-qualified doctors were

contracted to work longer hours, closely supervised, had their work regularly

scrutinised and had low morale in comparison to UK-qualified doctors. In the

workplace, they found discrimination and racism were not confronted by the

institutional structures and policies linked to E&D. These findings are from research

investigating the working experiences and career opportunities of skilled and low-

paid BME workers in the health sector.

Using findings from a literature review, interviews with DoH policy advisors, NHS

employers, TUs and health service managers, semi-structured biographical

interviews and statistical data, Healy and Oikelome (2006) emphasised that BME

workers had to work harder than their white counterparts to succeed. Over 50% of

the participants in the interviews revealed that they had experienced workplace

racism. Also, a person with an English-sounding name was more likely to be

shortlisted for a job than a person with a foreign-sounding name. Noticeably, Healy

and Oikelome (2006) are among the few researchers who link issues around class

and race together.

From their detailed research, Healy and Oikelome (2006) argued that initiatives

around E&D were focused more on changing individuals rather than changing and

challenging the culture of the NHS. They asserted more resources needed to be

invested to challenge and transform the organisational culture that prevented the

40

implementation of these schemes, and greater honesty and transparency was

needed from managers. In terms of producing effective change, there is a perception

that TUs are powerless to effect any positive change in the work setting and white

people are blinded to understand the nature of workplace racism.

The modernisation programme of the NHS has led to contradictions in the style and

management. Reflecting on the work of Pollitt and Bouckaert (2000), Cooke (2006b,

p. 224) catalogued the contradictions that were played out every day in the NHS as:

“• Increase political control but free managers to manage;

• Save money and raise standards;

• Motivate and empower staff but intensify work and downsize;

• Reduce bureaucracy but increase audit, measurement and juridification;

• Decentralize responsibility but centralize control.”

Cooke (2006b) argued that the search for cost savings and getting more with fewer

resources meant clinical staff carried heavy workloads, worked over and above their

contracted hours and experienced intense pressure that led to nurses complaining of

stress, exhaustion and low morale. Working in these circumstances made it difficult

for nurses to provide holistic and high standards of patient care and, hence, a

production line approach was adopted. Patient dissatisfaction led to nurses not only

bearing the brunt of complaints over poor standards of care with patient safety

compromised, but also being scapegoated and on the receiving end of disciplinary

action.

41

Cooke’s (2006b) findings demonstrated the contradictions identified above led to

tensions between nurses and managers over inconsistent and opposing

management style. Participants from her study referred to this as ‘seagull’

management which denoted:

“We have seagull managers here, they fly in from a great height, make a lot of noise,

drop a lot of crap, then they fly off again.”(p. 223)

Cooke (2006b) described seagull management as consisting of four characteristics:

1. Managers who rarely visited the clinical area or visited if there was a

complaint/serious incident;

2. Distrust between managers and clinical staff. Clinical staff mentioned feeling

unsupported;

3. Destructive criticism in the form of clinical staff being humiliated and shamed;

4. Defensive culture adopted to counteract complaints, litigation and bad publicity.

In another study, Cooke (2007) investigated scapegoating that was hidden and in the

subconscious and unconscious of organisations. She defined the scapegoat as: “one

who is blamed or punished for the sins of others” (Cooke, 2007, p. 178). Her theories

of scapegoat are drawn from psychoanalysis and also the work of Girard (1986) and

Bonazzi (1986). Her findings came from data drawn from interviews with ward

managers/charge nurses, staff nurses, managers, TU representatives and directors

of nursing. Data was also collected from observations and documents. The findings

discussed the unpopular nurse, the incompetent ward manager and the

insubordinate nurse.

42

Drawing on her findings, Cooke (2007) profiled the characteristics of the unpopular

nurse as: an outsider who did not fit in the team; a problem nurse no one wanted to

protect; someone not pulling their weight; somebody set up by the team to fail; a

person taking the blame for the rest of the team; somebody vulnerable. The

environment where errors and standards of care fell below acceptable levels was

often chaotic, highly charged with inadequate staffing and low morale. Rather than

recognising shared responsibility for the delivery of poor standards of care, one

individual was blamed. From her data, Cooke (2007) showed that the unpopular

nurse was singled out and held to account for the misdemeanour.

Cooke (2007) also identified incompetent ward managers as scapegoats. Usually

they were accused and disciplined for managerial incompetence around the failure to

cope with reorganisation of services. There was a failure by senior figures to think

about the wider systems and processes leading to the failings. Using the theories of

Bonazzi (1986) on ‘instrumental scapegoating’, Cooke (2007) argued that holding the

ward manager responsible excused Trust executives and higher managers, who

introduced the poorly planned changes, from blame and accountability. Attention

from those in power and instigators of change was averted.

Another group identified as scapegoats were nurses labelled as insubordinate and

described as ‘having a bad attitude’, ‘bad apples’ and ‘troublemakers’. Nurses with a

bad attitude were those who challenged the status quo and were frequently

subjected to disciplinary action. Outcomes of dealing with insubordinate nurses were:

to move them to other clinical settings; make an example of them to warn others

what would happen if they questioned the authority of higher management.

43

From a literature review, and using the work of Murray (2005), Stone et al. (2011)

linked suspension with: low morale and bullying often by managers; increased

workloads; harassment and conflicts with colleagues or managers that led to

complaints and insubordinates facing disciplinary action. Reflecting the assertions of

Henry (2000) and Oulton (2003), Stone et al. (2011) emphasised that errors did not

occur because nurses were reckless or poorly trained. They happened as systems in

organisations were not designed to prevent errors from occurring.

Following a Freedom of Information Request sent to 24 Trusts in London, the Royal

College of Midwives (RCM) found 60% of midwives had been subjected to

disciplinary action (RCM, 2012). To understand this issue, the RCM suggested,

organisation culture, poor management practice, poor leadership, lack of awareness

of E&D and the attitudes of all staff needed to be investigated. However, as the

findings of the RCM (2012) were limited to London, it was unclear if this problem

existed across the country, and so more research is needed.

Researching BME staff involvement in the disciplinary process, Archibong and Darr

(2010) revealed several findings in the areas of management practices and

competencies as well as organisation culture.

Their results about management practices highlighted: inconsistent application of

disciplinary policies with line managers finding it difficult to deal with disciplinary

issues involving BME staff; some managers lacked confidence in applying informal

strategies, particularly when dealing with minor issues involving BME staff; BME staff

were more likely to be disciplined over insignificant matters; HR managers felt BME

staff were not treated fairly; line managers were using disciplinary procedures

44

inappropriately to deal with performance issues; some managers could not deal with

a diverse workforce and manage conflict effectively.

In terms of organisation culture, Archibong and Darr (2010) found that issues of

equality were not always considered in formulating and putting policies into

operation. They also found that Trusts adopted a subtle culture that rebuked

employees who did not follow the conventional organisational customs and the issue

of race could influence the decision to discipline staff.

A recent scoping study commissioned by the NCAS and undertaken by Traynor et al.

(2013) concentrated on the conflict between managers and healthcare professionals

in the management of poor performance among UK nurses and midwives. From the

evidence gathered, Traynor et al. (2013) found NHS Trusts managed poor

performance in a costly and unsatisfactory manner. The lack and low quality of data

on poor performance publicly available served these organisations as they could

conceal their practices and shun scrutiny.

Drawing on the work of Berg (2006), Traynor et al. (2013) reported the authority of

managers was challenged by clinicians, particularly doctors. The relationship

between managers and clinicians was marked by different concerns and challenges.

For some managers, the main priority was control over healthcare professionals,

their spending and increasing their outputs. Traynor et al. (2013) also acknowledged:

the vulnerability of NHS managers, particularly around the pressures they faced to

meet targets set by central government; increased monitoring by external and

internal bodies; the outbreak of serious incidents around patient safety and dignity as

reported in the local and national media. Finally, Traynor et al. (2013) noted:

45

“As members of a relatively weak professional group, nurses who are disciplined

carry the individualised blame for organisation failings such as poor resources, poor

training and target driven cultures.” (p. 6)

The solution prescribed by NHS Trusts for better training, clinical supervision and

appraisals has not addressed the complex systemic and political aspects of the

issue.

2.4.5 E&D agenda

The racist murder of Stephen Lawrence in 1993 led to the MacPherson Inquiry in

1999. Following the inquiry, the Labour government introduced the Race Relation

(Amendment) Act 2000 that has placed a statutory general duty on public bodies to

promote race equality. Since the introduction of this legislation, greater attention and

a higher profile has been given to E&D policies and practices. In spite of the DoH

claiming that the NHS was making improvements in E&D, Healy and Oikelome(2006)

reported scepticism expressed by BME staff who felt wary of the stream of schemes

and that these initiatives made no impact.

Carter (2000) reinforced the findings of Beishon et al. (1995) that equal opportunities

policies: were poorly communicated; lacked information; were paper commitments

that held little significance; were poorly embraced and put into practice and lacked

direction. He added two other significant findings from his study: equal opportunities

policies were marginalised when economic pressures were placed on hospitals to

control their budgets; managers were resistant to incorporate equal opportunities

policies when appointing staff.

46

Covering the changes of the past 25 years around the E&D agenda, the Wainwright

Trust (2012) reported the key achievements and challenges that remained. It

highlighted: a greater awareness of prejudice-based inequalities; discrimination was

institutionalised and indirect; E&D was on the political agenda. It identified ongoing

challenges as: inserting E&D in practice and the mind-set; discrimination driven

underground; political correctness; the limited understanding of racism and

institutionalised racism; the Conservative–Liberal Democratic coalition government’s

lack of commitment to E&D as economic challenges took priority; the coalition

government possibly reversing employment protection law.

To collect the data, the Wainwright Trust (2012) sent out four questions to everybody

on its database. Recruitment and respondent details were not disclosed in its report.

In the report, the Trust acknowledged that the findings were not representative and a

comprehensive study was needed. It is unclear how many of the views expressed in

the responses are personal or the views of the organisation.

Alleyne (2005) studied the impact of race equality training and analysed the

perceived motivating factors of NHS managers seeking equality training for their

staff. She asserted:

“The immediate pay-offs for the organisation are creating an acceptable face to the

external world and a sense of security within. Guilt, shame and blame are temporarily

absolved from the organisation’s conscience, and everyone can sit back with an ease

of mind that they have done the right thing.” (p. 3)

A sense of cynicism prevails that NHS Trusts could be ‘seen to be doing’ and tick the

box of complying with E&D policies in their organisations. Alleyne (2005) emphasised

47

the training received had minimum bearing and impact on staff attitudes and

relationships.

With a background in psychotherapy and research involving diversity and stress in

the workplace, Alleyne (2005) analysed her experiences as an independent trainer

facilitating training groups for public sector staff undertaking diversity training. Using

a psychodynamic approach, she examined the working relationships in how

employees address issues of difference, prejudice and oppression in their teams and

workplace.

Alleyne (2005) found that the agenda of managers commissioning the training was

vast, muddled and homogenised. There was an unrealistic expectation from

managers that this agenda could be covered in half a day. Alleyne (2005) interpreted

this as: the organisation and staff perceiving ‘blacks are all the same’ and ‘black

people being seen only as special and victims’; the request to allocate the bare

minimum of time was an avoidance to look at the primitive fears in the unconscious;

denial was used to evade the complexity of emotions surrounding race and culture.

Rather than engage with the unpleasant strong emotions, processes and reactions,

employees looked for prescriptive and cognitive recipes in how to behave and what

language to use. Using ‘politically correct’ language exempted staff and organisations

from being labelled “racists”.

Alleyne’s (2005) other findings were: sessions were highly charged with hostility and

ambivalence; resistance was encountered when individuals and groups were

challenged about their defensive behaviour; white participants in the session

experienced shame and took up a guilt-ridden position due to Britain’s colonial and

48

imperial past when black participants discussed oppression. Absolution of these

feelings led, in some situations, to white people asking for forgiveness from black

participants.

In Alleyne’s (2005) study, her psychodynamic approach focused on the psychological

unconscious forces operating within the psyche of individuals, teams and the

workplace. She has tried to understand in depth and go beyond the adverse

challenges of how people related to each other in the complex area of race and

culture. However, there are drawbacks to her study particularly around the questions

asked about the lack of rigour and the scientific evidence base of psychodynamic

approaches used.

Despite this rhetoric stance from the then Labour government to its commitment to

the E&D agenda, the Audit Commission published The Journey to Race Equality in

2004. It directly addressed what prevented progress to race equality in the public

sector. In the main, the auditors reported organisations needed to address

institutional behaviours that hindered positive outcomes for BME groups. These

behaviours were found in institutional racism reported in The Stephen Lawrence

Inquiry, Report of an Inquiry by Sir William MacPherson of Cluny (1999). The Audit

Commission (2004) identified the main barriers as: low priority given to race equality;

lack of understanding about incorporating race equality in day-to-day work;

insufficient resources allocated; difficulty relating to BME groups; too many or too few

objectives.

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2.5 Summary of literature review

The disproportional representation of BME staff in the disciplinary process in the

NHS came to the attention of Parliament in 2008. On behalf of the NHS Institute for

Innovation and Improvement, Archibong and Darr (2010) undertook a study to

investigate this phenomenon. They found BME staff over-represented in the

disciplinary process. It was difficult to ascertain the extent and depth of this issue as

there is no centralised body collecting quantitative and qualitative details on

disciplinaries in the NHS. The literature reviewed predominantly involved nurses.

The literature review on disciplinary hearings and BME staff has been divided into

five sections: disciplinaries outside the NHS (including international studies and other

sectors); poor performance, suspensions and disciplinaries in the NHS; presentation

of BME staff; organisation and management culture of the NHS; E&D agenda. Some

of the themes overlap. Anecdotal evidence has not been included in the review.

From the literature review, various qualitative methods (including web audits, focus

groups, interviews, scoping studies, case studies and questionnaires) have been

identified as methods of investigation. There is a dearth of studies that specifically

focus on BME staff and the disciplinary process in the NHS. Carter (2000) and

Archibong and Darr (2010) are the exceptions. Studies on disciplinaries have been

included in the review even though they might not directly refer to BME staff.

2.6 Gaps

The seminal study by Archibong and Darr (2010) specifically considered the

neglected area of the disproportional representation of BME staff involved in the

50

disciplinary process. However, the authors did not acknowledge their study

limitations which, on closer inspection, are:

1. Professions, ‘overseas qualifiers’ and BME staff are homogenised. The different

BME groups working in the NHS are not identified.

2. Rationale behind disciplinary actions is needed and the type of disciplinaries

used by managers was outlined in the study. No definition of ‘disciplinary’ or

‘disciplinary proceedings’ is given.

3. The researcher, being an instrument to the study, is absent. As researchers,

Archibong and Darr relied on participants’ perceptions and experiences and

incorporated these into their final findings. The realities of what participants have

witnessed and shared with the researchers are valid. As there are ‘multiple

truths’, Archibong and Darr’s own ‘realities’ could not be ascertained or offer

another dimension to the findings.

4. There is no literature review of the disciplinary process relating to BME staff in

the NHS.

5. The study findings fail to recognise critical studies that have investigated some

areas of disciplinary action and proceedings in the NHS. For example, the

important work of Hannah Cooke (2006a and b; 2007) on scapegoating and

examining the disciplinary process in the NHS is ignored.

6. There is a lack of attention to the wider context of the continuous changes and

reconfiguration of the NHS. The pressure to make savings, which led to a

shortage of nurses and services being redesigned when public expectations and

51

demands continued to grow, is not addressed. The consequences of how this

impacts on the roles and responsibilities of staff and the tension and dynamics

created in teams, working relationships and ultimately on the quality of patient

care, were not wholeheartedly considered. The bigger picture of the politics of

daily life in the NHS is sidestepped in the study.

7. It is hard to ascertain from the study if Archibong and Darr had direct contact with

BME staff undergoing the disciplinary processes. The study findings are based

on the perceptions of participants who only seem to be senior staff who are

presenting the views of the majority. Contradictory views are shunned.

8. Apart from two semi-structured interviews carried out with representatives from

the General Medical Council and NMC, all the data is collected within group

settings. Participants in group settings could be silenced from expressing what

they actually think and feel if their views were against popular opinion and were

controversial.

2.7 Formulation of the research question

In light of the dearth of research, no studies using ethnography have been found in

the literature search to investigate the over-representation of BME staff involved in

the disciplinary process in the NHS. There is also an absence of research examining

the disciplinary process in terms of investigations, hearings and staff directly involved

in this process. Although the Trust (where this study will be undertaken) has

recognised there is a disproportional representation of BME employees involved in

the disciplinary process (this phenomenon) over the past five years, the reasons are

unclear as no research has been undertaken to investigate this phenomenon.

52

The research question is ‘what are the key factors that influence the over-

representation of BME staff in the disciplinary process in this Trust?’ This is an

exploratory study to determine and begin to understand why this phenomenon exists.

Ethnography is used as the methodology. This study will build on the work of Carter

(2000), Cooke (2006a and b) and Archibong and Darr (2010) by adding another

perspective to an under-researched area.

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Chapter 3: Methodology

3.1 Introduction

This chapter begins with an outline of a qualitative approach that embraces

ethnography. Justification for using ethnography as a methodology to meet the study

aim is outlined. Focus is then on how the Trust was secured and accessed to carry

out this research. The ethnographic aspects used in this study to collect data through

fieldwork, secondary data, participant observations, semi-structured interviews and

journal/diary are discussed and presented in Figure 1. Recruitment and selection of

participants are then considered. The recording of data precedes the thematic

analysis that is used to analyse the data collected. Ethical matters relating to this

research are addressed. Finally, reference is made to reflexivity.

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Figure 1: Study process and data collection methods

55

3.2 Qualitative approach

Qualitative and quantitative research have been presented as opponents with

randomised and controlled trials being distinguished as the best. This debate is

questioned by Mays and Pope (1995) and considered superfluous as:

“The crucial question, therefore, is not what is the best research method? But what is

the best research method for answering this question most effectively and efficiently.”

(Al-Busaidi, 2008, p. 1)

Qualitative research is compatible with discovering the meaning that people place on

events, processes and structures of their life experiences, behaviours and beliefs (Al-

Busaidi, 2008). Attention is given to the social context where people live and work

and researchers want to gain an understanding from the perspective of participants

in how they construct their social world. With qualitative research, there is no single

truth but multiple realities that are there to be described and discovered. To access

the subjective realities, researchers need to enter the participants’ social world,

experience their culture first-hand and engage with them in their day-to-day lives.

Qualitative research emphasises that a phenomenon needs to be studied in a holistic

manner and not isolated and reduced into multiple parts (Ryan et al., 2007).

Qualitative research relies on the researcher to act as the research instrument (Pope,

2005) and conduit for language, beliefs and experiences to be shared by the

members of the group being studied. As the researcher is immersed in the field, the

similarities and differences in the human experiences of the cultural group and

setting are brought to the surface and analysed. The subjectivity of using a qualitative

method where the researcher and research are directly connected has its challenges

56

(Topping, 2010). Critical self-reflection of the researcher’s own predisposition and

biases need to be examined (Polit and Beck, 2012). This process is also known as

‘reflexivity’ and discussed further at the end of this chapter.

Qualitative methods aim to explore the social problems that a culture or group of

individuals experience (Goodson and Vassar, 2011). Ethnography in particular is

different from other qualitative research methods as it concentrates on culture and is

used to highlight sensitive areas and give voice to marginalised and unspoken issues

in health care (Dixon-Woods, 2012). For this study, ethnography is used to meet the

study aim, which is to determine the key factors that influence the over-

representation of BME staff in the disciplinary process in an NHS Trust.

3.3 Research site

This section has been included as the Trust had some effect on the methodology,

particularly around the size of the sample selected. Before, and in addition to, putting

a research proposal together for ethical clearance, it was pivotal to secure a research

site. It would have been futile to undertake the proposed research study without

having an NHS Trust willing to participate.

Trying to initiate a study to investigate the disproportional representation of BME staff

in the disciplinary process presented numerous issues and obstacles. The first was

selecting a Trust where the phenomenon of the over-representation of BME

employees involved in the disciplinary process existed. The next stage was to

negotiate and establish relationships of trust with key senior influential figures so that

access to the site could be obtained for the study to be undertaken. As well as finding

and accessing a research site, a research proposal needed to be composed so that

57

ethical approval could be granted for a study to be carried out. The rationale for

selecting the Trust as a potential research site was:

1. The initial online search identified the Trust as having a disproportionate number

of BME staff involved in the disciplinary process;

2. I had a connection with the Trust;

3. In terms of practicalities, distance and travel, the potential research site was

accessible and manageable to collect data.

The nature of the research subject is regarded as a sensitive area. McGarry (2010)

described sensitive research as “intimate, discreditable or incriminating” (p. 8). For a

Trust to allow a researcher into its setting to conduct a study on a sensitive ‘taboo’

subject, such as the disciplinary process involving its BME staff, could raise much

anxiety, particularly as it is unclear what the findings would reveal, including potential

repercussions for the Trust.

3.3.1 Negotiating and gaining access to the Trust

Currently I work at a university that is connected to the Trust. As a researcher who

has some position of an ‘insider’ in the Trust, there are certain advantages. Bonner

and Tolhurst (2002) described these advantages as: rapport and relationships are

already established; there is some understanding of the culture being studied;

disruptions are minimised. The potential drawbacks are: the research perspective

being lost if too much rapport with participants is established; the balance between

objectivity and subjectivity being impeded; familiarity with the environment leading to

assumptions being made and subtle data being ignored (Bonner and Tolhurst, 2002;

McGarry, 2006). Consideration of having a connection with the Trust before the start 58

of the study and the impact of this relationship is discussed further under section 3.12

Reflexivity.

Before making any ethical application to the University Research Ethics Committee

(UREC) and the local NHS Research and Development (R&D) ethics committee, key

employees in the Trust were contacted. Pope (2005) stated:

“The point of entry and alliances with powerful gatekeepers in the organisation

influence how group members perceive the research.” (p. 1180)

The identified gatekeepers had a significant role, particularly around sanctioning the

study, providing access to the Trust site, sources of data and meetings needed for

participant observations. Six meetings were held over a four-month period. During

the intervals between our meetings, the gatekeepers consulted and discussed the

proposed study with colleagues involved in E&D issues related to the workforce and

disciplinary process. Simmons (2007) stressed that the relationship between

gatekeepers and bodies they liaise with is important. She said:

“The more trust the group places in the gatekeeper, the more trust is extended to the

ethnographer.” (p. 13)

Emphasis in the dialogue with senior managers and gatekeepers focused on the

balance between the benefits, risks and potential outcome of the study. It was made

clear that the proposed research would not involve service users, carers or any form

of clinical trials. Potential participants would be Trust employees involved in

disciplinary-related matters and their participation would be voluntary.

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To gain authorisation, as needed for the NHS Site Specific Information form, some

amendments stated by a Trust Board executive needed to be made to the original

research proposal. The word ‘apparent’ needed to be inserted into the title as it was

not definite in the mind of one Trust Board executive that there was an over-

representation of BME staff in disciplinary hearings. The initial number of 12 semi-

structured interviews needed to be increased to a minimum of 20 so that there was

more representation and depth in the study. (The sample size of 12 was also queried

by the UREC who stipulated that this needed to increase.)

The changes were discussed with the academic supervisors. Consideration was

given to this study being the intellectual property of the researcher and autonomy

being maintained over the methodology used to investigate the phenomenon. This

was balanced with the need to secure a research site. It was agreed to make the

changes. Once ethical clearance had been approved, a working space, honorary

contract, title of honorary researcher, identity badge and parking permit were issued

by the Trust.

3.4 Ethnography as a methodology

The word ethnography is derived from the Greek ethnos meaning people/folk and

grapho meaning to write (Cull, 2011). From this translation, ethnography is writing

and describing particular people. It is not simple to define ethnography as there is

extensive uncertainty about what ethnography is (Savage, 2006) and there have

been many variations and interpretations of ethnography (Lambert et al., 2011).

According to Hammersley (2006), there are issues in describing ethnography as

there is no standard definition due to its complex history. As a methodology,

ethnography has originated from anthropology and sociology. Today the discipline of

60

ethnography has become so wide and complex to describe that it has been marked

by diversity rather than consensus (Atkinson and Hammersley, 1994). Focused and

critical ethnography (as explained in 3.4.3 and 3.4.4) are used in this study.

3.4.1 Rationale for using ethnography

To reiterate, the study aim is to determine the key factors for the disproportional

representation of BME employees involved in the disciplinary process in an NHS

Trust. To understand this phenomenon, it was important to get on the inside of the

Trust and examine the context, culture, structures, procedures and the personnel

involved in the disciplinary process. Ethnography encompasses a method to

investigate this.

Rather than relying on a single approach, additional methods commonly used in

ethnography were adopted to support the fieldwork in the Trust, triangulate the

findings and maintain rigour. These other methods included collecting secondary

data, undertaking participant observations and conducting interviews in the natural

setting.

As established in the literature review, no ethnographic studies were found on the

over-representation of BME staff in the disciplinary process in the NHS. Methods

identified in the review were web audits, workshops, focus groups, case studies,

interviews, semi-structured interviews and questionnaires. By undertaking an

ethnographic approach, this study will add another layer to the existing knowledge in

order to understand this complex, challenging and under-researched area.

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3.4.2 Characteristics of ethnography

Despite there being no consensual definition of ethnography, Skeggs’ (2001)

definition of ethnography has been applied as this encapsulates the ideas used in

this study. She described ethnography as:

“A theory of the research process – an idea how we should do research. It usually

combines certain features in specific ways: fieldwork that is conducted over a

prolonged period of time; utilizing different research techniques; conducted within the

settings of participants, with an understanding of how the context informs the action;

involving the researcher in participation and observations; involving an account of the

development of relationships between the researcher and researched and focussing

on how experiences and practice are part of a wider process.” (p. 426)

Ethnography does not come under one epistemological belief. The assortment of

ethnographic approaches are differentiated by epistemological and ontological

perspectives such as naturalism, realism, relativism, modernism and postmodernism

(Savage, 2006). There are several ethnographic approaches: classical, critical,

feminist, narrative and focused. Focused and critical ethnography are used in this

study.

3.4.3 Focused ethnography

Focused ethnography is a useful method in capturing data on a specific topic or

shared experiences (Higginbottom et al., 2013). The main attributes identified by

Muecke (1994) – and reasons for using focused ethnography in this study – are:

1. Problem-focused and context-specific – the issue is the apparent over-

representation of BME staff in the disciplinary process;

62

2. Focus on a discrete organisation phenomenon – the unexplored phenomenon

exists in an NHS Trust;

3. Conceptual orientation of a single researcher – one researcher undertaking this

as part of a taught clinical doctorate programme;

4. Involvement of a limited number of participants – this involves staff engaged in

the disciplinary process;

5. Episodic participant observation – as I was undertaking the taught clinical

doctorate programme on a part-time basis and needed to complete the study

within a specific time frame, only periodic participant observations could be

undertaken in the field;

6. Participants hold specific knowledge – the staff involved in the disciplinary

process hold experiences and knowledge about the phenomenon;

7. Used in academia as well as for development in healthcare services.

3.4.4 Critical ethnography

Critical ethnography is influenced by critical theory that perceives reality produced by

social, political, cultural, economic, ethnic and gender values (Denzin and Lincoln,

1994). Critical theory centres on understanding power relationships, social structures,

oppression and social justice (Vandenberg and Hall, 2011).

Critical ethnography focuses on social oppression and injustice by highlighting issues

related to power and control (Madison, 2004). Institutions and social practices that

restrict choice, denigrate identities and communities are scrutinised. Using critical

ethnography for this study is fitting as BME employees highlighted in the literature

63

review are more likely to be disciplined than their white counterparts in the NHS

(Archibong and Darr, 2010; Royal College of Midwives, 2012; South East Coast BME

Network, 2008).

3.5 Core concepts from ethnography

Any ethnographic approach has two principle concepts, which are at the core of this

methodology: culture and fieldwork (Lambert et al., 2011).

3.5.1 Culture

According to Roper and Shapira (2000), questions that should guide the study are:

“What is it like being a member of the particular culture? What are the rules guiding

social behaviour?” (p. 3)

The knowledge that is gained from these questions by the researcher needs to be

contextualised in the wider setting. Does what goes on in the system reflect and

mirror what goes on in other systems, the wider organisation and society? Is the

culture specific to the setting? Can new insight be found from the study and add to

existing knowledge?

One of the main objectives of ethnography is to interpret culture (Fetterman, 2010).

Ethnography can reveal the culture of people’s natural workplace setting. This is

done by examining and understanding the patterns of employees’ social interactions

and their interpersonal relationships with colleagues who occupy the same space.

Holloway and Todres (2010) defined culture as:

“A way of life of a group, the learnt patterns of behaviour that are socially constructed

and transmitted. This includes shared communication system in language, gestures

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and expressions – the message that most cultural members understand and

recognise.” (p. 166)

Individuals in groups share behaviours, differences and diversity. This needs to be

considered as culture is not homogenous and something that operates on its own.

Institutions, such as hospitals, are complex cultures within themselves (Goodson and

Vassar, 2011) and various cultures intertwine and operate at the same time. In a

complex and challenging organisation, such as the NHS, the context is constantly

changing and this has a bearing on the culture. Historical, social, political and

economic forces on the conscious, subconscious and unconscious level also exist

(Obholzer and Roberts, 2003). These forces impact on the cognitions, behaviours

and emotions of staff. How much of these dynamics influence and reflect how

employees perceive themselves, their relationships with others and how they function

in groups and the organisation setting needs to be elicited and interpreted by the

researcher. Fetterman (2010) described this as ‘cultural interpretation’. Being

culturally immersed (Streubert and Carpenter, 2011) in the field allows the researcher

to see the power of dominant values, beliefs and ideas operating in the organisation.

This falls in line with critical ethnography.

The other core concept of fieldwork is discussed in the next section.

3.6 Methodology

The methods used from ethnography to collect data were fieldwork, secondary data,

participant observations, semi-structured interviews and journal/diary.

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3.6.1 Fieldwork

Primary data collection in ethnography is undertaken through fieldwork. Fieldwork is

one of the core traits of ethnography. Wolcott’s (1995) described fieldwork as:

“A form of inquiry that requires a researcher to be immersed personally in the

ongoing social activities of some individual or group carrying out the research.” (p. 3)

According to Roper and Shapira (2000), ethnography is a process of learning about

people by learning from them. An insider’s view is obtained to understand the

phenomenon investigated in its natural context. For this study, 63 days (472.5 hours)

spread over three months were spent in the Trust collecting data related to

disciplinaries, as outlined earlier in Figure1 in section 3.1.

Being in the field allows the researcher to observe, ask questions and compare what

people say they do with what they actually do in their work settings. Watching what

happens in the moment and noting the subtleties, congruence and incongruence of

verbal and non-verbal communication first-hand lie at the heart and strength of

ethnography (Lambert et al., 2011). Being in the field allows the researcher to

experience the culture and witness how people relate to, perceive and construct their

social world (Reeves et al., 2008). Tacit and latent information is revealed. Research

methods such as surveys, questionnaires and interviews do not capture this valuable

data.

Ethnographic research is produced by the quality of the relationship between the

researcher and participants through emic and etic viewpoints.

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3.6.2 Emic and etic perspectives

The important theoretical concepts of emic and etic were derived from the works of

Kenneth Pike, a linguist, and Marvin Harris, an anthropologist. Using emic and etic

approaches in ethnography reveal different perspectives when the same

phenomenon is being investigated and analysed by the researcher from the inside

and the outside (Brown, 2003).

Emic research is undertaken inside the group to investigate the culture of systems,

whereas the etic approach is conducted outside the group through observing the

actions and behaviours of people in their natural settings. The emic method

considers the views of members of the group; in this study it was the various

employees involved in the disciplinary process as they held specific knowledge,

values, beliefs and experiences. In addition, the emic approach allows the researcher

to access and uncover spoken and unspoken rules and rituals of the culture

(Holloway and Todres, 2010).

The emic approach in ethnography allows the researcher to observe and investigate

the subjective reality of the insider. Where there are people from diverse ethnic and

racial backgrounds linked to a specific situation, such as disciplinaries, multiple truths

and realities exist. These subjective realities might not conform to the reality, norms

and conventional values and beliefs of the majority culture (Fetterman, 2010). Issues

around the differences in roles, relationships and dynamics between employees not

apparent to the outsider become evident to the researcher on the inside. The

dynamics that occur in and from these complex and configured relationships on

many levels in people’s working lives can highlight issues of power, authority,

inequality, control and conflict, and how they affect the culture of teams, groups and

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the organisation involved in a specific situation (Smith, 2001). The role of critical

ethnography is also taken into account here.

For the purpose of reflexivity (which is described in section 3.12), the position of

having a connection with the Trust before commencing the study was considered.

The impact of this as an insider and outsider during the collation of data was

reflected on in my research journal/diary. These aspects, together with field notes

made during participant observations, were discussed with academic supervision.

The work of Bonner and Tolhurst (2002) was considered. The benefits and the

drawbacks of insider and outsider were closely monitored. As an insider, the

following benefits were noted: I had some awareness beforehand of how the Trust

performed; relationships with some employees (in my role as a university lecturer)

were already ascertained; with rapport and trust already established in some parts of

the Trust, disruption could be minimised, particularly during participant observation.

The potential disadvantages considered were: the focus of the research could be lost

by having too much affinity and closeness with research participants; ‘over-familiarity’

of the Trust might lead to making assumptions and subtle data being overlooked;

conflict in my roles and responsibilities as a lecturer and researcher.

Although I was known in some parts of the Trust, I was unfamiliar with the areas and

personnel involved in the disciplinary process. From an etic perspective, this had

benefits: knowing little about a specific culture, situation or event allowed some

research participants to share personal information with myself as I was perceived as

being impartial and not as a threat; subtle differences were observed and routines

that were taken for granted by research participants were sensitively discussed to

seek further clarification. However, the disadvantage of being an outsider and based

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within the HR department aroused some speculation about impartiality and trust. As

participants were observed in the field, they could feel they were being inspected,

judged and might not conduct themselves naturally in the presence of the researcher

(Dixon-Woods, 2012). From the onset, the study was presented as the initiative and

sole property of the researcher. Potential recruits were informed the research had

undergone scrutiny by the Trust and university ethics committees to ensure the

identity of participants would be protected.

In undertaking ethnography, the researcher needs to strike a balance of being an

‘insider’ and ‘outsider’ (Bonner and Tolhurst, 2002). As part of reflexivity, the position

of the researcher needs to be monitored in academic supervision as this can affect

the quality of data collection and analysis.

3.6.3 Secondary data

In traditional ethnography, the use of written material and documents is overlooked.

Hammersley and Atkinson (2007, p. 128) stated:

“It is easy (but wrong) to assume that the spoken account is more ‘authentic’ or more

‘spontaneous’ than the written.”

They later asserted (p. 129):

“There is still, apparently, a tacit assumption that ethnographic research can

appropriately represent contemporary social worlds as essentially oral cultures.”

Secondary data refers to existing data (Dixon-Woods, 2012). On face value, existing

data is valuable as this provides initial insight into the depth and extent of the

phenomenon being investigated and how the organisation represents this issue and

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themselves in the public domain (Atkinson et al., 2001). For the researcher, written

material in formal and informal texts allows access to the social world and provides

another piece of the jigsaw regarding the context, structure and purpose of the

organisation in relation to meeting its tasks to manage employees who have

transgressed. Existing information available online to the general public provided a

surface picture of the culture of the organisation and the size of phenomenon. Insight

into the opinions of employees, particularly diverse and marginalised groups, was

obtained from Care Quality Commission (CQC) reports, NHS staff surveys and

statistics around disciplinaries.

This gathering of available secondary data online helped to identify gaps, generate

the research question and decide on the methodology to investigate the

phenomenon. Once permission and ethical clearance were given to collect data in

the Trust, existing written information not available to the general public and wider

staff on disciplinaries was attained. Documents related to the over-representation of

BME in disciplinary hearings were also obtained, some more easily than others.

These included: the Race Equality Scheme (RES); minutes of the RES; Equality and

Diversity Framework; Trust Interim Equality Objectives; Service and Workforce

Equality Report particularly on the descriptive statistics around disciplinaries; Trust

Board meetings where E&D issues were discussed; NHS Staff Survey for the Trust;

previous audits into disciplinaries; draft action plans; quarterly Trust magazine; and

information from the Trust intranet.

The validity, use and value of this written data needs to be considered and then

triangulated with other methods used to obtain findings (Roper and Shapira, 2000).

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3.6.4 Participant observation

As with ethnography, there is no single agreed definition of participant observation

(Savage, 2000). Polit and Beck (2012) exemplified participant observation as:

“Periods of intense social interaction, between the researcher and participant, in the

participant’s socio-political and cultural milieu.”(p. 544)

Participant observation in ethnography has its origin in anthropology (Watson et al.,

2010) and is increasingly used as an instrument to produce more in-depth knowledge

of a culture in healthcare research (Holloway and Todres, 2010). Observation and

participation are another hallmark and core activity of ethnography allowing the

researcher an opportunity to immerse in the lives of others and describe how

participants perceive their world (Emerson et al., 2001) by looking, listening and

asking questions (Roper and Shapira, 2000). Participant observation is used to

investigate the social life of people in their natural setting. The researcher is looking

through the cultural lenses (Streubert and Carpenter, 2011) of the participant and

putting aside their own perceptions and assumptions. An insider’s experience is

looked for. What is ascertained from participant observation in ethnography is

summarised by Mack et al. (2005, p. 14):

“Participant observation is also useful for gaining an understanding of the physical,

social, cultural and economic contexts in which study participants live; the

relationships among and between people, contexts, ideas, norms and events; and

from people’s behaviours and activities – what they do, how frequently and with

whom.”

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Gold (1969) stressed that there are four levels of observation detected in

ethnography:

1. Complete participant – the researcher fully participates in the activities and

observations might be done with or without the group’s or individual’s knowledge.

Examples for this study were engaging with employees during informal and

unstructured times such as lunchtimes, before and after meetings;

2. Participant as observer – most of the time by the researcher is spent participating

in activities of those being observed with less time spent on formal observations.

Examples for this study were attending meetings covering workforce issues;

3. Observer as participant – participation by the researcher is brief with most of the

time spent observing activities and people. Examples for this study were

predominantly in meetings when employment matters relating to disciplinaries

were discussed;

4. Complete observer – the researcher just observes people, behaviours,

interactions or events and had no interactions with the observed. Examples for

this study were attending Trust Board meetings and a formal disciplinary hearing.

Researchers move between these levels and generally occupy the ground of

participant as observer and observer as participant. The levels of participant

observation undertaken are not always linear and depend on the role, position and

situation of the researcher. Balancing and combining the roles of observation and

participation in ethnography and how passive or active the researcher should be can

be confounding. The level of trust, rapport and connectedness depends on the length

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of time the researcher is immersed in the field and the relationships that are formed

with participants.

Spradley (1980) identified three types of observation: descriptive observation is

undertaken at the start of the study when the ethnographer enters the social situation

to gain an overview and find out what is going on; focused observation concentrates

on selected events and interactions related to the aims of the research; selective

observation looks at specific features of activities, processes, culture and people.

For this study, participant observations were undertaken in the following areas within

the Trust:

Disciplinary hearing x 1;

Trust Board meeting x 1;

BME Staff Group x 3;

E&D Group (quarterly meeting) x 1;

Race Equality Steering Group (quarterly meeting) x 1;

Workforce Equality Group (quarterly meeting) x 1;

Senior Nurses Forum x 1;

Trust executive leaving event.

3.6.5 Interviewing

Informal conversations and formal in-depth interviews allow the researcher

opportunities to gain further clarification, understanding and meaning of behaviours

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and language that might not be comprehensible during participant observation

(Holloway and Todres, 2010). Interviews have the ability to describe, explain and

explore subjects from the participant’s stance (Tod, 2010).

Within the definition of ethnographic interviewing, Heyl (2001, p. 369) stated:

“Researchers have established respectful, on-going relationships with the

interviewees, including enough rapport for there to be genuine exchange of views

and enough time and openness in the interviews to explore purposefully with the

researcher the meaning they place on events in their world.”

This definition differentiates ethnographic interviewing from other types of interviews

by empowering participants to focus in their own language on cultural meaning of

actions and events. Participants are in a position to share personal experiences of

their interpersonal relationships and the cultural value they encounter in their daily

lives. To achieve this task, the interviewer needs to spend a considerable amount of

time building a rapport and relationship with participants. The concept of rapport

generates mutual respect, empathy and understanding so a safe space can be

created for the participants to share their viewpoints (McGarry, 2006). This, in most

cases, was achieved as some participants were able to share their perceptions and

feelings around disciplinaries openly and frankly. However, owing to the limited time

spent in the field, it was difficult to do follow-up interviews, as is discussed further in

section 8.3.

3.6.5.1 Semi-structured interviews

After observations, interviews in ethnography are an important source of information

to gather understanding and subjective meaning (Fetterman, 2010). For this study,

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27 semi-structured interviews were undertaken with employees directly involved in

the disciplinary process. Semi-structured interviews are commonly used in

ethnography (Fetterman, 2010). Pre-determined questions and themes within an

interview guide were used. This flexible framework allowed the researcher to vary the

wording and order of the questions to suit each interview (Dearnley, 2005). Open-

ended questions allow the researcher to explore further issues with the participant

that arise on their own accord and that have not been anticipated (Doody and

Noonan, 2013).

3.7 Selection, recruitment and undertaking interviews with

participants

This section looks at how employees were chosen for the semi-structured interviews.

3.7.1 Selection – inclusion and exclusion

Having identified the issue to investigate and gained access to the site, consideration

was given to selecting and recruiting employees from the Trust to participate in the

study. Fetterman (2010) identified two methods: choose who and what not to study;

select who and what to study. To manage, carry out and investigate the phenomenon

realistically under the time constraint, ‘purposive sampling’ (Polit and Beck, 2012)

was used to select employees, events, settings and documents associated with the

disciplinary process.

The eligibility criteria (Polit and Beck, 2012) were that participants should be Trust

employees and able to give informed consent. These included all types of employees

in different roles and positions; both male and female; from white and BME

background; and involved in the disciplinary process.

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The exclusion criteria (Polit and Beck, 2012) included employees unable to give

informed consent and where, through participation, there might be adverse effects to

their well-being.

3.7.2 Recruitment

After selecting the type of participants to be interviewed, attention was paid to

recruiting volunteers. Once ethical approval had been granted, time was spent

disseminating the study in the Trust. A synopsis of the study was put on the Trust

website with contact details. Employees were contacted by email and telephone.

Attached to the initial email were the invitation letter (Appendix 2), participation

information sheet (Appendix 3) and consent form (Appendix 4). Follow-up face-to-

face meetings were arranged to discuss the research with staff expressing interest in

the study. Presentations were also made to the Senior Nurses Forum, E&D Group,

BME Staff Group and the Race Equality Steering Group to discuss the nature and

purpose of the study. After the presentation, time was set aside to answer questions.

Written details of the study were also provided for interested staff to look at the

details of the research at their leisure. Reactions to the study and resulting

behaviours noted during participant observations are highlighted in sections 6.3.5

and 6.3.6.

3.7.3 Special measures taken for employees who had been investigated

Recruiting potential participants who had disciplinary action brought against them

was given further consideration. The UREC asked for special measures to be taken

when approaching and recruiting these employees. In this instance, to minimise

further distress and harm, the researcher did not directly contact the employee.

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Instead he liaised with a third party (the TU representative) who was directly involved

in the disciplinary process and could pass on the details of the study.

This sampling method, known as ‘snowballing’ where one person (i.e. the

researcher) finds another (i.e. the TU representative), is useful with those who are

difficult to recruit (Streubert and Carpenter, 2011).

Relying on TU representatives to pass on details to employees who had a

disciplinary action initiated against them had drawbacks. Officials admitted that

details were not always passed on as they would ‘forget’. Employees under

investigation and without TU representatives could not be contacted to participate in

the study.

3.7.4 Undertaking interviews

To reiterate, employees who were interested in participating in interviews were given

the invitation letter, participant information sheet and consent form. The interviews

with willing participants were conducted at a time that suited their convenience and a

place where they felt safe. Some interviews took place in participants’ offices. Before

the interview was conducted, the information given was again discussed, queries

answered and, if the employee was satisfied to continue, the consent form was

signed. The interviews on average lasted up to one hour. Approaches to promote

diversity and antidiscrimination practices during interviews are discussed under 3.12.

3.7.5 Outcomes from the interviews

There were 27 participants who volunteered to be interviewed for this study. They

included: employees under investigation; members of the disciplinary and appeals

panel; investigating officials and support; TU representatives; witnesses; and

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members of various groups where workforce issues related to disciplinaries were

discussed. For reasons of ethics (see section 3.11), the specific roles and positions

of participants involved in the research are not identified in this study.

3.8 Data recording

For this study, field notes, fieldwork journal/diary and transcriptions of interviews

recorded on digital audio equipment were used. The digital audio recorder was only

used for the interviews with prior consent.

3.8.1 Field notes

Field notes are a conventional technique used in ethnography to document data.

Handwritten field notes were used for participant observations and interviews where

audio recording was deemed unsuitable and could hinder meaningful dialogue and

interaction with participants. Undertaking field notes is a selective process as it is not

possible to encapsulate everything. Hammersley and Atkinson (2007) suggested

when to write field notes and what to write down are significant when data is being

collected.

1. When to write down – the timing of writing down notes can impact on the

situation. Participants can become self-conscious when notes are recorded. This

distraction can disrupt and affect the natural flow of interactions and generate

mistrust. In some meetings, I could not write anything down as participants were

sitting next to me and observing what information I was writing on my notepad. In

these situations, detailed field notes were made as soon as possible after the

meeting had ended;

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2. What to write down – attention needs to be paid to the form and content of what

is documented. Owing to the mass of data accumulated for this study, selection

had to be made between breadth and depth of notes, capturing significant

events, experiences and interactions in the field (Emerson et al., 2001). In this

study, I recorded significant events related to disciplinary matters in my field

notes. Some field notes from participant observations related to the physical

environment, the mood and atmosphere of the setting, seating arrangements, the

level and depth of interactions and non-verbal behaviours. This information could

not be captured by audio digital recordings (Gibbs, 2007). Depending on the

situation, written information ranged from detailed actual words to jotting down

key phrases and words. Chapter 6 will discuss data collected from field notes.

3.8.2 Digital audio recording

Undertaking the traditional method of pen and paper during long interviews has its

pitfalls as the finer details and focus can be lost. A digital audio recorder was used

when participants consented to its use during semi-structured interviews. As well as

assuring the accuracy of capturing the interview verbatim (Gibbs, 2007), this could

allow active engagement and listening by the researcher so additional questions

could be formulated and asked (Roper and Shapira, 2000). However, being recorded

can hinder participants from speaking in a frank and open way.

After the interviews, the recordings were transferred into a password-protected

computer and erased on the audio digital recorder. Each interview was fully

transcribed and on completion was double-checked by reading the transcript in

conjunction with listening to the interview for accuracy.

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3.8.3 Fieldwork journal/diary

In addition to field notes, a separate fieldwork journal/diary was kept during the

research. For reflexive purposes, it was important to examine aspects of my own

subjective lived experience and the potential impact this had on the study so biases

and prejudices could be identified and addressed (Emerson et al., 2001). This

journal/diary captured emerging ideas, gut reactions and reflections of my own

thoughts and feelings. This material was considered in the context of the study. For

example, when I felt despondent about senior managers showing a lack of interest in

the study, I associated this to various initiatives from the E&D agenda such as the

RES and the Equality Delivering System being on the periphery of the Trust. The

E&D agenda, as discussed in section 6.3.4, was not embraced by the Trust Board

and had little impact to the working lives of BME staff. Adopting this approach

allowed me space to be objective, avoid becoming stuck and not to take issues

personally.

3.9 Data analysis

Having collected data from the field, participant observations, transcribed interviews

and documentary sources, the next stage involved analysing this data. There is no

single agreed method or a ‘once size fits all’ approach for analysing data in

ethnography (Angrosino, 2007). The collection and analysis of data in ethnography

simultaneously starts in the field at the outset. This continues in order for additional

investigations to be carried out to address questions that have not been anticipated

so that further data can be collected as the research progresses (Rebar et al., 2011).

Ethnography aims to explain the culture. Identifying cultural themes involves careful

scrutiny of the data collected. Analysis involves looking for patterns in behaviour,

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thoughts and the rules of the group studied. The analysis proceeds to an overview of

what people believe and how they behave in their social setting (Roper and Shapira,

2000). Latent patterns become clearer in understanding the culture in relation to the

phenomenon investigated (Polit and Beck, 2012).

3.9.1 Thematic analysis

For this study, thematic analysis devised by Braun and Clarke (2006) is used to

examine the data. They defined thematic analysis: “as a method for identifying,

analysing and reporting patterns (themes) within data” (p. 6). Their framework has six

phases, which are:

Phase 1: Gaining familiarisation by reading and rereading the data so that depth and

content are attained. Through this process ideas and patterns begin to emerge;

Phase 2: Generating initial codes to arrange the data into meaningful categories;

Phase 3: From all the data that has been coded and collected, overarching themes

are revealed;

Phase 4: Reviewing themes that support the data;

Phase 5: Defining and naming each theme;

Phase 6: Producing the scholarly report.

This qualitative research tool provides a flexible approach to evaluate areas that are

under-researched. Thematic analysis is not dependent on specialised theory. How

thematic analysis is applied to findings uncovered will be discussed in the next

section.

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3.9.1.1 Presentation of findings from the data collected

Having spent time in the field, vast amounts of data was accumulated. The next task

was to structure and analyse the data and then present the identified themes. The

data analysis was considered in the context of focused and critical ethnography. It

involved interpreting and examining: the impact of political, social, economic and

historical forces permeating into the Trust; the various cultures operating in the Trust

where disciplinaries were taking place; the diverse staff group employed and their

experiences of being in the Trust; the phenomenon under investigation; the multiple

realities of the vast range of employees involved in the disciplinary process; the

relationships, structures, systems and processes involved in disciplinaries. The

purpose of adopting this approach was to begin to identify and understand the key

factors for the disproportional representation of BME employees involved in the

disciplinary process in the Trust.

To aid this process, thematic analysis devised by Braun and Clarke (2006) was used.

After the data was collected, time was spent to familiarise myself with the data

corpus from the interviews, participant observation, field notes and secondary data.

For the semi-structured interviews (that made up most of the information collated),

careful attention was given to active listening of the recorded interviews in

conjunction with active reading of the transcripts, so depth and breadth could be

obtained from the data. This lengthy, complex, challenging and absorbing process

was repeated many times to draw out and define the themes.

Not all the information from the data corpus was used in this study. For this study, the

data set refers to all the data presented for the phenomenon investigated. The data

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item is each interview, participant observation, journal/diary or secondary data

utilised to make up the data set. Once the data set had been extracted from the data

corpus manually, overarching themes were identified, reviewed, refined and coded.

To ensure validity, rigour and reliability of the analysis, methodological and data

triangulation was used. All the data collection methods were used in the analysis.

The data collected from the interviews, participant observations, field notes,

journal/diary and documents were then compared and contrasted to determine the

themes and multiple realities related to the phenomenon. As most of the data was

collected from interviews with participants occupying different roles and positions,

multiple realities and perspectives were captured and reported.

Overarching themes are identified and presented in this chapter and summarised in

Table 1 in section 6.7: the context of the Trust; perceptions of BME employees in the

Trust; perceptions of the disciplinary process; perceptions of employees directly

involved in the disciplinary process. Each of the four themes has sub-themes.

Issues did arise from applying thematic analysis to determine and present the

findings. With the vast quantity of data collected, it was overwhelming, particularly

around how best to proceed. Observance of maintaining objectivity of the data

collected and not making premature interpretations before all the data was analysed

was closely monitored. Academic supervision over this period was invaluable.

3.10 Triangulation

To test the quality of the data gathered, triangulation is commonly used as a tool in

ethnography. Triangulation is a principle used in surveying land (Gibbs, 2007). This

metaphor is used in ethnography where a phenomenon is analysed from different

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perspectives (Rebar et al., 2011). Two or more methods are used to substantiate the

findings from one source with the other (Simons and Lathlean, 2010). The application

of multiple strategies provides a more holistic and improved understanding of the

phenomenon and improves the validity and reliability of the data (Streubert and

Carpenter, 2011).

Relying on a single method can limit the scope and depth of the study (Hammersley

and Atkinson, 2007). For this study, methodological and data triangulation were

used. Methodological triangulation is when the methods used to collect the data are

compared and contrasted to offer a thorough insight into the phenomenon

investigated (Reeves et al., 2008). In this study, field notes, participant observations,

interviews, journal/diary and secondary data are weighed against each other during

data analysis. Data triangulation involves using a range of data sources from different

settings (Simons and Lathlean, 2010). Data collected from various employees

occupying different roles and positions in the disciplinary process are examined.

Their experiences were compared and contrasted so that multiple realities related to

the phenomenon in the Trust could be obtained.

3.11 Ethics

The research governance in the UK seeks, promotes and maintains high standards

of research (Griffiths, 2008). The design, methodology and how the research is

undertaken must be rigorous, transparent and trustworthy (Johnson and Long, 2010).

All research conducted in the NHS requires ethical approval to safeguard participants

from risk and harm. The purpose of an ethics committee is to ensure and maintain

the legal rights of research participants and the following principles are strictly

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observed: autonomy; informed consent; dignity; non-coercion; privacy; confidentiality;

and non-maleficence (Griffiths, 2006 and 2008).

The research proposal did not need to be approved by the National Research Ethics

Service (NRES) as the study did not involve patients and carers. However, the

proposal needed to be approved by the UREC and the Trust’s own R&D ethics

committee. The submission of the first application to the UREC was rejected as it

wanted: the number of samples to be increased; clarification about anonymity of staff

who had been through the disciplinary process and were willing to participate in the

study; amendments to the structure of language on the patient information sheet;

clarification of how employees who had been investigated under the disciplinary

process would be approached. These issues were addressed and the proposal was

then accepted by the UREC. With the amendments incorporated, the Trust’s R&D

ethics committee also accepted the proposal.

Measures were put in place to safeguard participants. It was anticipated that

particular issues around a discomforting and sensitive subject could arise for the

Trust and employees participating in the study. During one interview a participant

became emotional. A break was taken until the participant was ready to continue. On

their return, the participant stated they were aware they could withdraw from the

study but wanted to continue with the interview.

For ethical reasons related to protecting the anonymity of the Trust, its employees

and groups, the identities, roles and backgrounds have not always been disclosed in

this study as some of the employees could be easily identified. Deductive disclosure

takes place when groups and individuals could be identified in research reports

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(Kaiser, 2009). The breach of confidentiality and anonymity by deductive disclosure

is a concern of the researcher as ethnographic studies contain a wealth of personal

experiences and opinions about research participants and groups. The concerns are

that research participants could potentially face negative consequences if their

identities are exposed. Each participant in this study was given an identification

number so their anonymity was protected and details of their participation were

stored in locked filing cabinets and password-protected computers. This was to

minimise potential harm and uphold the principle of non-maleficence.

3.12 Reflexivity

Reflexivity is a significant feature of ethnography in assessing the quality and rigour

of the research process. Cruz and Higginbottom (2013) stated:

“Reflexivity is focussed on making explicit and transparent the effect of the

researcher, methodology and tools of data collection on the process of the research

and the research findings.”(p. 42)

Researchers come into the field with their past experiences, prejudices, culture,

attitudes and belief systems intact. If these factors are not monitored and critically

scrutinised, they can inevitably impact on the investigation and ultimately the findings

of the study. To minimise biases, reflexivity as a critical self-reflection process is

undertaken (Vandenberg and Hall, 2011). In the course of this self-examination, the

researcher is constantly enquiring about the effect on the process and outcome of

the study and the research on the researcher (Pellat, 2003). In particular, attention is

given to the potential effects of the interpersonal dynamics in social situations. The

researcher’s own position of power and privilege needs to be considered and brought

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to the fore. These dynamics can influence how the data is collected and analysed

(Walker et al., 2013).

In the field notes, connections with the Trust and the impact of this relationship

before the start of research have already been acknowledged in section 3.6.2.

Reflecting on the relationship was important in that the role adopted for the research

was different to my previous roles and responsibilities occupied in the Trust. To

support my position as a researcher, a sabbatical was obtained to concentrate solely

on the study. In introductions at formal and informal meetings, I stated my role of

‘honorary researcher’, which was further reinforced and displayed on the identity

badge worn and visible at all times.

Consideration was also given to being a male, coming from a BME background and a

migrant from a country that was once ruled by Britain during the course of this study.

The motives for carrying out a politically charged study were reflected on in my

journal/diary. My knowledge, experience and clinical skills as a mental health nurse

and a qualified psychotherapist were utilised in the study. Aspects of self-awareness

were brought to the fore. My behaviours, thoughts, emotions and fantasies were

frequently checked before, during and after interactions with participants and the time

spent in the Trust collecting data. This was to monitor distractions as I did not want

these to influence how I was observing, participating, listening and reporting during

the collection and analysis of data. For example, what was analysed from participant

interviews needed to be separated from my own perceptions, subjectivity and

partiality.

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For this study, attention was also paid to: not homogenise BME and white

employees; look beyond ‘black versus white’ dynamic; allow for differences to

emerge within and between the different BME participants and groups. To help,

Papadopoulos and Lees’ (2002) model of cultural competence in research was

incorporated in the study. Through cultural awareness, my own personal values,

beliefs, attitudes and prejudices and how these might impact on the research process

were closely examined and reflected on. Coming from a Sikh background, the

historical aspect of Sikhs having been at war with Muslims and the British in the past,

was taken into account. It was important that historical conflicts on my part were not

subtly played out when engaging with Muslim and British participants. I was also

aware of how Sikhs in East Africa (where I was born) had subjugated black people in

their own homelands. Cultural knowledge was also reflected on. I realised my

limitations, that I was not always aware of every cultural nuance, particularly with

staff from the vast continent of Africa. I avoided making stereotypical assumptions

and was aware there was no such person as a ‘black African’. This allowed me to

reflect on the difference, similarities and inequalities between and across ethnic

groups. Through cultural sensitivity, power relationships and potential oppressive

practices, my interactions with participants were closely monitored. For example: I

always asked participants where they wanted to be interviewed so they had the

choice to be in a safe and comfortable environment; I took into account the age,

disability, gender, sexual orientation (as openly revealed by one participant), race,

culture and religion of Trust employees. In my interactions, I was careful not to agree,

disagree, collude and offer interpretations to what participants were reporting. Where

possible I tried not to interrupt and allowed for silence to prevail. Attention was given

to the non-verbal cues and verbal communication in order to maintain a non-

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judgemental stance. During the interviews, consideration was given to the physical

environment such as the decor, lighting, seating arrangement and gender

positioning. When participants were happy to come to a venue of my choice, identical

chairs were selected. On entry to the room, I gave the participant a choice of which

chair to sit in. A small table with a box of tissues was placed in the room just in case

someone became upset. When I was invited by participants to be interviewed in their

offices I was always aware where I was asked to sit. There were several occasions

where the participants being interviewed sat behind big desks. All these participants

were white managers. On a couple of occasions, participants answered their

telephones or responded to people who were knocking on their doors during the

interviews. On one level, as recorded in my journal/diary, I found this behaviour

irritating and had to be aware not to react. On another level, I considered this

behaviour in the context of the study and related this to the lack of authentic

engagement and commitment from managers regarding E&D issues and how they

perceived BME staff in the Trust.

Regular academic supervision was also undertaken with two supervisors who were

outside of the Trust and in a position to challenge the positionality of the researcher.

3.13 Summary

In this chapter, the methods adopted from ethnography to achieve the study aims

have been presented and discussed. Rationale to explain why focused and critical

ethnography were used has been provided. Obtaining ethics and gaining access to a

Trust and the ethnographic methods of fieldwork, participant observations, interviews

and secondary data used to investigate the over-representation of BME staff involved

in the disciplinary process have been highlighted. The process of analysing the data

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through thematic analysis has been outlined. To improve the quality and validity of

the data and minimise bias, triangulation and reflexivity have been discussed.

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Chapter 4: Descriptive statistics

4.1 Ethnic profile of the population the Trust serves

The most recent (2009) figures of the ethnic profile of the local population served by

the Trust are presented in Figure 1. Most of the served population is white

comprising white British, white Irish and other white background. When the 2009

ethnic profile of the local population is compared to that of staff working for the Trust

in 2011 (Figures 2 and 3), there are some notable features: 80.1% of the local

population is white compared to 54% (1305) of white staff working for the Trust;

18.5% of the local population are from BME backgrounds compared to 38% (918) of

BME staff. If the Trust staff figures are further broken down to specific ethnic groups

and comparison is made between the local population and those staff groups,

notable aspects are observed: 5.6% of the local population are black compared to

27% of black staff; the percentage of the local population of Asians compared to

Asians working in the Trust is similar – 9%.

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Figure 1: Population served by the Trust – 2009 (data source: Census, Office for

National Statistics, 2009)

However, making comparisons between the percentage of the ethnicity of the 2009

local population and that of the staff employed in 2011 by the Trust, needs to be

treated with caution as there is no information currently available of how many Trust

staff also live among the local population served by the Trust.

4.2 Workforce profile

There is only descriptive statistical data available for 2011 and 2012 and none for

2008 to 2010. During 2011 the total workforce of the Trust was 2416. Note that

figures in parentheses indicate number of Trust staff.

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4.2.1 2011 profile

Figure 2: Ethnicity profile of staff

As shown in Figure 2, 54% (1305) of staff employed by the Trust come from a white

background and38% (918) from BME groups. In Figure 3, the percentage of each

group has been further broken down.

Figure 3: The ethnicity and percentage of each group

White British are the largest group of staff within the Trust (991 and 42%) and black

African staff are the largest group (459 and 19%) within the BME workforce.

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Figure 4: Ethnicity of occupational staff groups

Within the Trust, BME staff comprise the largest group within ancillary, nursing,

HCAs/support staff and other medical roles. White staff prevail in the positions of

consultants, senior management, allied health professionals (AHP), AHP assistants,

psychology and psychotherapy.

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Figure 5: Registered nurses (693)

Within the role of nursing, BME staff represent over 60% (423) of this professional

group.

Figure 6: Registered nurses – ethnicity and banding

In 2010, Agenda for Change paybands and gradings were introduced in the NHS.

Newly qualified registered nurses start at band 5 and progress to band 8, which is

divided into four bands – a, b, c and d. As the graph clearly shows, the number of

BME nurses declines as they progress through to the higher bands. With the white

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nurses, the proportion of numbers increases as nurses move up the banding

hierarchy.

Figure 7: Ethnicity of HCAs/support staff (349)

There is a higher proportion of BME staff within the HCA and support staff role

relative to the numbers of BME people in both the Trust 2011 workforce and the 2009

local population served by the Trust. This is reflected in the higher numbers of BME

HCAs and support staff from bands 2 to 5 (see Figure 8).

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Figure 8: Ethnicity and banding of HCAs/support staff (349)

In comparison to 2011, the workforce numbers decline slightly from 2416 to 2330 in

2012. The Trust has also changed its presentation of data in its 2012 Service and

Workforce Equality Report. This will be reflected on in chapter 7.

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4.2.2 2012 profile

Figure 9: Ethnicity profile of staff

In comparison to the previous year, there is no change in the number of staff from a

white background. There is a 2% increase in the numbers of BME staff employed by

the Trust. As described earlier, 80% of the 2009 local population served by the Trust

is white (Figure 1); however, this group makes up 54% (1258) of the Trust 2012

workforce. The opposite picture is found when the black population is examined.

Although 5.6% of the local population is black, this group has risen to 26% (606) of

the Trust 2012 workforce. Asians make up 9% (210) whereas others represent 6%

(140).

In Figure 10, the ethnicity of non-medical and non-nursing staff is shown. Overall the

percentage of white staff increases as they progress up the bands. The opposite is

observed for black staff whose numbers decrease. For other BME groups, the

proportions are too small to make significant comments.

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Figure 10: Ethnicity of non-medical staff and non-nursing staff (bands 1–5)

In Figure 11, there is a higher percentage of white staff in each band in comparison

to BME staff.

Figure 11: Ethnicity of non-medical staff and non-nursing staff (bands 6–9)

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In comparison to the 2011 figures, the Trust has grouped together HCAs and

registered nurses in its 2012 Workforce Equality Report. This will be reflected on in

chapter 7.

Figure 12: Ethnicity of nursing staff (bands 2–4)

Within Figure 12 significant differences are noted. The numbers of BME nursing staff

decreases from bands 2 to 4. There is a reverse trend for white staff.

A similar pattern emerges in Figure 13 with the proportion of white staff increasing in

numbers and a reverse trend occurring for BME staff moving up the banding

hierarchy.

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Figure 13: Ethnicity of nursing staff (bands 5–8c)

In Figure 14, higher proportions of white staff occupy each medical staff group apart

from specialist registrars and staff grade.

Figure 14: Ethnicity of medical staff

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4.3 Disciplinaries

The total workforce number in the Trust was 2330 for 2011 to 2012. There were 56

disciplinaries during that period, that is, 2.4% of the total workforce (Figure 15).

Figure 15: Disciplinary figures from 2008 to 2012

When comparison is made about the number of disciplinaries from 2008 to 2011,

there has been a slight decline. From 2011 to 2012, there was an increase in the

number of disciplinaries at a time when there was a small decline in the total

workforce in the Trust.

Figure 16: Ethnicity of disciplinaries from 2008 to 2009

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In Figure 16, the outcome of each category for 2008 to 2009 is broken down by

ethnic group. During this period there were 37 disciplinaries. Of these, 12 (32%) were

people who reported their ethnic background as white (British or other) and 25 (68%)

were from BME backgrounds. Data for the type of BME group was not available from

the Trust. In terms of the outcome of each disciplinary, no formal action was taken for

18 of these, action was taken outside of the disciplinary process for five individuals,

four people received a first written warning, five staff received a final written warning

and five were summarily dismissed. For four of these outcome types (no formal

action, action outside the process, final written warning and summary dismissal), the

number of BME individuals is higher in each group.

Figure 17: Ethnicity of disciplinaries from 2009 to 2010

From Figure 17, BME employees involved in the disciplinary process receive higher

levels of sanctions in comparison to their white counterparts in the following areas:

final written warning, dismissal, summary dismissal and resignation.

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Figure 18: Ethnicity of disciplinaries from 2010 to 2011

From Figure 18, there is a noticeable difference in the number of BME staff receiving

final written warnings and summary dismissals in comparison to their white

counterparts facing disciplinary action. In other areas of no formal action, first written

warning, dismissal and resignation, there is no difference between the two groups.

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Figure 19: Ethnicity of disciplinaries from 2011 to 2012

In comparison to the previous four years (2008–2011), there has been an increase in

the number of staff involved in the disciplinary process; 80% of BME staff went

through the disciplinary process. For the first time, data for suspension of staff is

reported in the Workforce Equality Report. BME employees are suspended almost

three times more than white staff (21:8). Sanctions of first written warning, final

written warning and summary dismissal are higher for BME staff in comparison to

white employees.

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Figure 20: Disciplinaries in terms of banding from 2011 to 2012

Before the publication of the Trust’s Workforce Equality Report, the Director of

Workforce and Deputy Director of HR stated that disciplinaries undertaken in the

Trust were at a lower banding. These figures reveal three times as many staff from

bands 5 to 8 are involved in the disciplinary process than employees from bands 1 to

4. However, the ethnic profile of these staff is not available from the data.

4.3.1 Reasons for disciplinary action

The types of issues, which have emerged over the past four years, that have resulted

in disciplinary action could be categorised as: unprofessional behaviours towards

colleagues; unprofessional behaviours towards patients; misconduct; other.

4.4 Conclusion

The population served by the Trust is predominantly white. Some areas have a

higher proportion of BME groups than white groups. In the Trust, the gap between

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white and BME groups has narrowed in the workforce. Black Africans are the largest

group within the BME group. Within nursing, HCAs/support staff and ancillary

occupations, BME staff comprise the largest groups. There are more white staff in

the position of consultants, senior management, AHPs, psychology, psychotherapy

and AHP assistants.

The numbers of BME nurses declines as they progress to the higher banding. There

is an opposite trend for white staff in nursing. A similar picture between BME and

white staff appears in medical, non-medical and non-nursing groups. For HCAs and

support staff, there is a higher proportion of BME employees.

There is a slight decline in disciplinaries from 2008 to 2011. From 2011 to 2012 there

is an increase in disciplinaries. During this period, there is a slight decline in the

numbers of staff employed. In each of the categories white staff never exceed their

BME counterparts.

Suspensions and bandings appear for the first time in 2011/2012. There is a higher

proportion of BME staff suspended in comparison to their white counterparts. Also,

more staff are disciplined in bands 5 to 8 than 1 to 4. More BME staff are put through

the disciplinary process than white staff. BME employees receive more first and final

warnings and summary dismissals than white staff.

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Chapter 5: Observation of a disciplinary

hearing and interviews with three employees

involved in the case

5.1 Introduction

This chapter focuses on the findings taken from field notes of an observed

disciplinary hearing and interviews with three of its participants. The researcher did

not have access to written and other details of the case before or after the hearing.

Interpretation of the findings will be discussed in chapter 7.

5.2 Observation of a disciplinary hearing

From the disciplinary hearing, the following observations were recorded in the field

notes:

The hearing centred on a suspended BME employee, Joyce, who worked in the

community. Joyce was accompanied by a white TU representative. The management

case against Joyce was presented by a white investigating officer (IO) supported by

a white HR manager. The case was heard by a panel consisting of a white

chairperson (Paul), a white professional lead and a BME HR manager (Monica). A

BME witness (Sam) gave evidence to the panel. A note taker, who was white, was

also present. The hearing took place within the Trust site.

5.2.1 Disciplinary hearing

On meeting and formally shaking hands, I noticed that the palm of Joyce’s hand was

damp. Although she and her TU representative consented for me to observe and be

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present at the hearing, both of them separately declined to be interviewed. In another

room, I was introduced to Sam who was the only witness to the case. He was asked

to wait in the room until he was called by the chair. Sam was keen for me to observe

the hearing and interview him.

Before everybody convened into the room where the panel members were privately

meeting, there were pairings at opposite ends of the corridor. Joyce and her TU

representative had their backs to everyone. The IO and HR manager presenting the

case at the other end were whispering to one another. In between these pairings, I

stood alone. The atmosphere was tense and heavy.

In the meeting room, the tables were positioned in a rectangular shape. At one side,

Paul was sitting between Monica and the professional lead. Across from the panel,

Joyce and the TU representative were at one end and the IO and HR manager at the

other. There was a large empty space between these two pairs (a similar pattern to

the positions as noted when they stood in the corridor). I sat at the side near the note

taker.

Before the formal introductions, I was introduced to the hearing. Everyone present

was already familiar with my research. The chair asked if there were any objections

to my presence. There were none.

5.2.1.1 Employee under investigation

For most of the hearing, Joyce avoided eye contact and gazed at the surface of the

tables. She only gave fleeting eye contact to the panel when they were conversing

with her. Joyce barely looked at Sam when he gave evidence. She had prepared a

written statement. She read this out when asked by the chair if she wanted to add

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anything to her defence. As she started to read, Joyce became distressed, tearful

and inaudible. She pushed her statement to the TU official and asked her to continue

to read from where she had stopped. Joyce did not refute any of the allegations

made about her clinical practice and conduct.

Joyce had been suspended from her duties as there were concerns around

safeguarding issues. From the evidence presented, various colleagues had

expressed their concern over Joyce’s clinical practice, lack of engagement with her

clients and poor level of functioning for her grade. Another particular concern was

Joyce holding onto a credit card given to her by a client and not returning it. It was

unclear from the hearing what Joyce had done with the credit card.

An example of one of Joyce’s cases was given by the IO. In the space of nine

months, she saw one client four times. A support worker was also involved in this

case. Despite the support worker expressing his serious concerns to Joyce about the

well-being of this client on many occasions, Joyce failed to respond to the requests

and liaise with the worker. The clinical notes written by Joyce gave a different

account to the actual experience and reflection of the case. The quality of her clinical

notes also failed to mention mental health issues and action plans to maintain the

safety and well-being of the client. Concerns around Joyce’s clinical practice became

so great that the team manager (Sam) refused to give her new cases.

It was also reported that Joyce failed to engage with clinical supervision despite

being prompted verbally and via email by Sam to book supervision. This was ignored

by Joyce who, in her defence, perceived Sam did not like her and was going around

collecting evidence to build a disciplinary case against her. She also mentioned other

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poor-performing staff in the team who were not as closely scrutinised as she was by

Sam. Up until Sam had arrived, none of the previous managers had commented and

raised concerns about Joyce’s practice.

5.2.1.2 Clinical team and environment

The team was described as ‘difficult’ by the IO and later on by Sam when he was

giving evidence. There was recognition of the lack of continuity in managers as there

had been several within a short space of time. Each manager had their own system

of supervision that was different to previous ones and this led to some confusion in

the team around booking supervision. The team manager had the responsibility of

supervising 17 clinicians. Many of the clinicians in the team were from a different

discipline to the team manager. Some clinicians expressed their concern about

interdisciplinary supervision between social and health care. Sickness in the team

was high and this led to colleagues carrying extra workload to cover the sickness.

Morale in the team was low.

Since Sam had arrived to manage the team, Joyce and her TU official reported ten

members of staff had left: four had been suspended; two were moved to another

area; one had resigned; one had taken early retirement; two had been sacked.

5.2.1.3 Outcome of the hearing

A decision on the outcome of the hearing was not made on the day of the hearing.

Paul, the chair, stated he needed more time to reflect on the evidence presented with

panel members before he could arrive at a decision. He also informed Joyce that she

would receive the outcome within seven working days by letter.

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Joyce did return to the team and it is unclear if she received a first or final warning.

After this hearing, some members of the team, including Joyce, put in a collective

grievance against Sam. The contents are not known but both Sam and Paul mention

this grievance in their interviews.

5.3 Interviews

The observations recorded in the field notes presented what had happened in this

disciplinary case. The semi-structured interviews allowed an opportunity to probe,

seek further information and ask for clarity. Three employees from this hearing

consented to take part in separate semi-structured interviews: one interview took

place with the BME witness after the hearing; another with the white chairperson of

the panel was before the disciplinary hearing; the final one with the BME HR

manager sitting on the panel took place after the case had been heard.

5.3.1 Interview with Sam, the witness

The interview was conducted in Sam’s office. Sam has worked in the Trust for many

years. He comes from a BME background and has been a team manager for six

months. Before him, there has been a succession of six managers in two years.

Since joining the team, Sam has noticed poor clinical practice in the team and four

BME members of the team have been taken to disciplinary.

The themes elicited from the interview with Sam are:

5.3.1.1 Uncovering poor clinical practice in the team;

5.3.1.2 Managing a poor-functioning clinical team;

5.3.1.3 Impact of dealing with poor conduct and practice on Sam;

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5.3.1.4 Patient group treated.

Each of the themes is explored in depth.

5.3.1.1 Uncovering poor clinical practice in the team

Managing the performance and conduct of staff to deliver the highest standards of

care is an ongoing responsibility of the Trust.

5.3.1.1.1 Poor clinical practice and conduct

In terms of his appointment, Sam says: “I was quite shocked at some of the clinical

practices that were happening…. And within a very short period of time all these cases were

just hitting me in the face… and I thought ‘How the hell has this been allowed to go on for so

long?’”

One of the main issues Sam found was around poor practice related to medication.

He reports: “At one point the Trust has introduced something called the MMA, the

Medication Management Assessment… and at one point out of eight nurses I had six who

failed.”

5.3.1.1.2 Managers ‘turning a blind eye’

Sam also describes other poor practice that he has witnessed: “There were some

managers there… who let them get away with blue murder… I used to sit in team meetings

and everyone… they were all supplied with a laptop and everyone would be typing away and

doing this, doing that, I thought great. But then when I get up and walk around they would be

answering emails, they were catching up with progress notes on the system, they were

surfing the internet, whilst we’re talking about patients’ lives. And I always put myself in the

perspective of a patient and thought well, if I was being treated by this team, how would I

feel? And I thought no, this has got to stop, so I stopped them from doing it.”

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5.3.1.1.3 Déjà vu

The problems of the clinical team Sam manages are not new and senior managers

have been aware of these problems for a while. Preliminary measures have not

resolved the issues as they continue to persist. Sam conveys the team has been put

on an ‘At Risk’ register for the second time: “So it’s a team that has been seen as being

difficult. The team has been on the At Risk register before and is now on the At Risk register

again … So At Risk, in terms of how the borough directorate sees it, is this a team where

there have been numerous concerns and it could be about practice, low staffing levels, a

series of SUIs [Serious Untoward Incidents] etc.”

5.3.1.1.4 Collective responsibility

According to Sam, there has been some relief, particularly from the consultant, that

the long-standing issues around poor clinical practice and conduct are being picked

up. Sam states: “They were… pleased that I had seen it and noticed it and was doing

something about it.”

When Sam is asked how the consultant and other disciplines in the team are

collectively admitting there are problems in the team, he replies: “Well… they sort of

say… ‘It’s up to the managers to deal with’ and he was actually one of the consultants that

said to me that this has been going on for a long time, it’s always being tried to be tackled,

but down the succession of team managers it has always got lost…”

The many issues in this team have been left to one person to manage and deal with.

It is not surprising there has been a high turnover of managers in a short time.

5.3.1.2 Managing a poor-functioning clinical team

Several themes arose from this interview with Sam about his experience in managing

this service.114

5.3.1.2.1 Why had previous managers not stayed?

When Sam is asked if he has established why there has been a quick succession of

six managers, he replies: “I have reflected on it non-stop. It’s a difficult team, it’s a very

large team, it’s the largest team actually in the borough in terms of bodies and patients, and

it’s a bloody hard job in that team, it’s very, very hard. There’s too much for one person, way

too much…”

5.3.1.2.2 Ethnic composition of the team

Sam describes the ethnic composition of the team as: “It’s predominantly black British,

sort of black Caribbean, black British. At one point … when I first actually went into the team,

it was all black British, … in terms of what I call front-line staff…. Two white consultants, two

white secretaries and a black secretary…”

5.3.1.2.3 Joyce returning to the team

Sam mentions the team were given short notice of Joyce returning to the team: “We

notified the team on the Thursday that this person would be coming back on the Monday… it

was quite clear looking at her that I think she was struggling with being in a team where no

doubt people knew… about what had happened… But just looking at that person’s face…

they looked actually very unhappy about being back in the team, and very anxious…”

5.3.1.2.4 Poor uptake of clinical supervision

Although Sam is from another discipline, he found nurses in particular were avoiding

supervision with him: “The nurses weren’t booking in for supervision, I made it clear to the

Nursing Directorate I have got nurses who are not booking in for supervision because they

saw me coming from a non-nursing background…”

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5.3.1.2.5 Sam’s perceptions of how the team viewed him

Sam mentions how the team perceive him: “I think… some of them (not all of them)…

were extremely cautious about me… And I’d probably say they still are now because I’ve

come in, noticed these four cases and I am probably not very well liked because … ‘All these

staff are being disciplined since Sam’s been here,’ so I am probably seen as a bit of a devil

really.”

He declares trying to change the culture of the team has presented him with

numerous issues: “I am definitely seen as the enemy… and I think what has happened

because when I was in the team, and I thought God, I need more staff… and I got staff and…

I won’t say it’s made matters worse but the dynamics are more obvious, that the locum staff

that I have got in, … I have got five extra staff in, three white people and two black people

and within the team at the moment, because we have only been over here for about four

months, the new staff… are all sitting together, there’s not really that mix within the team, so

it’s like the original team members are all up one end…”

5.3.1.3 Impact of dealing with poor conduct and practice on Sam

Sam could discuss and share the impact this has had on him and the support that he

has received over this period.

5.3.1.3.1 Professional and personal toll

Sam states confronting the issues around poor clinical practice in the team has been

challenging: “It’s … not been very pleasant. … It has been tough, it has been difficult for me

at times… I was made aware that it was a difficult team, and I do like a challenge, but I didn’t

realise that it would be as bad as it actually was…”

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Sam declares the situation around Joyce continues: “…it’s been very, very stressful.

The person that has come back to the team two weeks ago, she has taken out a grievance

against me so I have got to go through that process…”

5.3.1.3.2 Support to manage the clinical team

Sam comments on the support he has received to manage the issues presented to

him: “The support that I had from my immediate manager was excellent. In terms of only one

particular person, there was just no support as well at all, and they were a very senior person

within the Nursing Directorate, I asked them to help me deal with these issues and I got no

help…”

Sam’s managers have provided additional support to help him manage the team:

“What’s happened now is it’s improved because the senior management listen to me and I

now have a deputy manager because it’s such a big team.… So that has improved things…”

Sam emphasises the support he has received from the HR department: “…the

support… and overall my opinion so far is that they have been very supportive…”

5.3.1.4 Patient group treated

Sam describes the type of clients the clinical team manage and treat: “Our client group

is 18–75 and we aim to work with people with a severe and enduring mental illness…there

are some sort of very risky patients.”

Sam perceives many of the clinical staff do not want to work with this type of client

group: “No, they don’t…. They … especially the nurses… prefer the more stable client group

with not a colourful risk history…”

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5.3.2 Interview with Paul, the chairperson

The interview took place in Paul’s office. Paul describes himself as: “I am not

traditionally a white English person, I am sort of from European stock…” As a general

manager, Paul has specific responsibilities related to disciplinaries. He: decides

whether an investigation should go to a hearing; has the authority to suspend staff;

chairs disciplinary hearings; makes decisions on outcomes and presents the cases at

appeal hearings.

The themes elicited from the interview with Paul are:

5.3.2.1 Uncertain future of the Trust;

5.3.2.2 Unveiling poor conduct and practice leading to disciplinary action;

5.3.2.3 Quality of staff supervision and support;

5.3.2.4 Undertaking the role of chair.

Each of the themes is discussed.

5.3.2.1 Uncertain future of the Trust

Paul discusses the uncertainty of the Trust’s future. He states: “It hasn’t helped by

having four chief [executives]… I think it does send out a very strange message to the staff

that what’s going on at the top is people can’t cope because… Certainly the last two

substantive chief execs, the impression we were given is that they didn’t leave to move on to

greater things, they left because they weren’t doing the job and I think there is a message

there that we’re telling some staff your performance isn’t up to scratch, you need to do better,

you need to work harder, and then people at the very top don’t seem to be doing their job,

don’t seem to be performing…”

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Economic pressures have forced the Trust to disaggregate and reconfigure its

services with posts being cut and clinicians carrying the extra burden of

responsibilities, as Paul conveys: “And I think there is also an issue with staff feeling

under pressure in terms of the savings that need to be made… and seeing that we are

having to cut posts on a continuous basis.”

To make savings, reduce inpatient beds and treat more patients in the community,

the Trust Board has been forced to scrutinise the performance of employees and

teams in delivering high-quality care. Paul reports: “I think things had been ignored for

some time so it was ‘Actually well we can’t, … we have got less and less resources, we are

looking at having to supply/do more with less’ and so there was ‘what we have got in terms of

staff resources we need to make sure we have got staff who are up to the job and whose

practice is safe’.”

5.3.2.2 Unveiling poor conduct and practice leading to disciplinary action

With services under close scrutiny, serious concerns have arisen about the conduct

and clinical performance of staff. Paul refers to Sam’s team: “Over the last year we

have had quite a number of disciplinary processes, which started when we were aware that

there was some significant concerns about performance… the concerns were so serious…

So… we have probably had around six or seven [disciplinaries] in the last year. I think in

terms of those staff from BME, probably five or six…”

The number of disciplinaries among BME employees in the staff team, as Paul

states, has heightened anxiety: “I can think of one particular team where the staff were

very concerned about well, who is next, and wanting some assurances that we weren’t just

out to get people and it’s very difficult to respond to that because you can’t give any detail

about why someone was suspended or why they were then dismissed, … it’s no one else’s

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business in a way but we’re very keen to try and get the message out that well actually, if

you’re doing your job, then you have got nothing to worry about.”

5.3.2.2.1 Ethnicity is not an issue

Paul is clear that ethnicity does not come into disciplining staff: “Someone’s ethnicity

isn’t considered as part of the facts, certainly they are not for me, but… it’s just actually ‘Is

their practice safe?’… ‘We are looking unfortunately to have to suspend someone this week,’

and actually saying ‘I am aware that this is going to be the fourth black member of staff who

has gone through the disciplinary process in the last couple of months,’ … because if you

need to suspend someone, you need to suspend someone…”

In light of Paul saying ethnicity is not an issue, he could not explain why there are a

number of BME employees involved in the disciplinary process: “No …I don’t think I

have.”

5.3.2.2.2 Grievance taken out

The heightened anxiety caused by the disciplinary cases in one team (to which Joyce

belongs) has resulted in a grievance lodged against Sam: “There were some concerns

raised about the number of BME staff who have been suspended… and a grievance was

submitted which included some allusions to that… this team manager was sort of trying to

get rid of BME staff on his team, regardless of the fact that he is from a BME background

himself…”

Paul explains the outcome of the grievance: “Well we looked at it in terms of getting it,

getting the grievance investigated as independently as possible… ‘We will get someone in

who has no history to look at this,’ …I think it found no evidence that that particular member

of staff was racist in any way… But the thing that did come up was around supervision and

the quality of supervision…”

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5.3.2.2.3 Managing the consequences from disciplinaries

Paul depicts a complex picture with many dilemmas presented to management when

a member of staff is disciplined: “We have had some very difficult conversations with

some of the team managers, they’re saying ‘Well what do I tell them? What do I say about

so-and-so…?’ and I say ‘Well you just have to say that they’re currently on leave’ … whilst

the disciplinary policy says if you are suspended you are not to make contact with members

of staff… I am pretty certain that people do because it’s human nature, especially if you have

friends who you work with, I am sure that they will then speak to each other… I am aware

that there have been some occasions where a member of staff has given a slightly different

version or perception of the circumstances than ours…”

5.3.2.2.4 Inconspicuous discussions on disciplinaries

Surprisingly in light of the emotions aroused, the wider discussion on disciplinaries is

low key in meetings as Paul expresses: “I don’t think it comes up very often to be

perfectly honest… For example we have an HR report which gets discussed… at our…

meetings which looks at the number of disciplinaries and the number of suspensions,

sickness procedures and that… but then it’s just numbers in terms of number of staff…”

5.3.2.3 Quality of staff supervision and support

With the Trust’s priority shifting from treating patients in the community, Paul

expresses his frustration: “There’s very little in terms of senior nursing leadership for the

community side which is where the bulk of our service users are…. And we need to address

that balance because at the moment we don’t have anyone, for example, to say ‘Right, OK, I

am going to implement and monitor a supervision structure for nurses.’”

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5.3.2.3.1 Lack of meaning of appraisals

All employees are expected to have an annual Performance Appraisal Development

Review (PADR) with their line manager to discuss their performance. The purpose of

this review is to reflect on the past year and agree objectives for the year ahead. Paul

questions the robustness of the PADR and links this to disciplinaries: “No, I don’t think

it’s a particularly meaningful process, especially sometimes given the timescales. It’s very

much people … saying ‘Let’s just get you in and get you out.’ …I think it’s very much focused

on the objectives – ‘This is what you should be doing’ which is helpful in terms of disciplinary

processes because then you can say ‘Well actually you knew that you shouldn’t do this, this

and this because it’s there and it was discussed and you agreed to it.’”

5.3.2.3.2 Lack of supervision and support as mitigating circumstances

In the disciplinary hearing, mitigating circumstances are allowed and presented to the

hearing by the employee under investigation and their TU representative. Paul

states: “The mitigating factors, I mean that’s why I am always keen to ask those questions,

… ‘Have you been having supervision and how often was it? If it didn’t happen, was it

because it wasn’t offered or that you didn’t take it?’ … and ‘What was in your development

review?’”

Paul discusses mitigating factors that were partly considered when professional

accountability around clinical practice was challenged in the hearing: “So with that

particular case, we ensured that that person had weekly supervision with a professional lead

because that was part of his defence ‘Actually I had no supervision, no one has raised these

issues with me,’ therefore we would take that on board. But actually… that’s not an entire

defence for your poor practice because you are a registered nurse and you should actually

know that just writing for example ‘depo given, seems stable’ every time you have seen that

person for the last two years isn’t really an adequate assessment of their mental state.”

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On other occasions, extenuating circumstances are deemed to be misleading as

Paul explains: “…sometimes they’re not [mitigating factors], and so you just think… ‘Hang

on, I appreciate you had some problems with your laptop, but your laptop working wasn’t the

reason that you didn’t identify safeguarding issues, … you don’t need a computer to know

that there’s a safeguarding concern for example.’”

5.3.2.4 Undertaking the role of chair

To undertake the role of chair, Paul explains he has had some training around

investigating cases: “When I was in… my previous role was when I was at a level where I

was more likely to investigate than present management cases, so it’s around the

investigation process and just… looking at all the steps. I mean it’s very similar… training in

how to investigate complaints as well, … there’s a process that you need to follow…”

5.3.2.4.1 Consequences of lack of training in making decisions on the outcome

Paul recognises there is a substantial shift from investigating cases to undertaking

the role of the chair to oversee the disciplinary hearing and process. He states there

is no training available in the Trust to assist in this transition: “Within this Trust very

little. I have had training in previous Trusts, but it was some time ago… So I have had some

training but there’s not a great deal of training available in the Trust…”

Paul comments on the potential consequences of the lack of training on making

important decisions: “And I mean I don’t know whether that then leads us to err on the side

of caution with not having had training and then being absolutely fully competent, but if you

are going to say ‘Right I am afraid…’ For example ‘We are going to dismiss you,’ maybe we

err on the side of caution and don’t dismiss if potentially we think it’s a good case…”

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5.3.2.4.2 Maintaining impartiality and fairness

Paul usually hears cases of employees from his own borough. Normally these are

heard on the evidence that is provided at the hearing and related specifically to the

allegation. However, Paul cites he would have information about the employee under

investigation that the other panel members would not have. In relation to Joyce, he

was versed in the long-standing problems and issues with individuals and the team.

Although not directly referring to Joyce, Paul acknowledges this added information

might have some bearing: “I would chair the hearings related to the teams that I manage,

and so inevitably if there have been concerns about a member of staff over the last six

months… I would be aware of that. If it then reaches a point where it’s a disciplinary issue,

you can’t just… park that information that you have been aware of…”

Paul emphasises disciplinary hearings chaired for another area are less problematic:

“It’s less of an issue if you’re chairing a disciplinary for another borough, … you have none of

the history… I know that I’m basing it solely on evidence that’s presented today because I

have never met you before…”

5.3.2.4.3 Maintaining impartiality and transparency

To maintain impartiality and transparency, Paul says: “It would be more helpful if we

just… made the process a little bit more independent by, for example, having managers from

a different borough or a different service hearing disciplinary cases, because I think then they

do come to it fresh and… it would add a layer of transparency to that…”

5.3.3 Interview with Monica, the BME HR manager

The interview with Monica was held a week after the observed disciplinary hearing in

her office. In the interview, Monica refers to Joyce’s hearing as well as to other

factors related to disciplinaries.

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Monica has many years’ experience as an IO and a panel member. In terms of

training to undertake the role in disciplinary hearings, Monica states she has been

given: “No specific training by the Trust, but it comes with the experience.” As a panel

member, Monica perceives her role as: “Ultimately as the HR practitioner you are

there to advise, not make the decision. So if you advise one thing and the general

manager is the decision-maker and wants to do something else, you have to stand

by the decision of…the panel chair.”

The themes elicited from the interview with Monica are:

5.3.3.1 Disaggregation and reconfiguration of services;

5.3.3.2 Training and experience of the chair;

5.3.3.3 Consequences of increased administration;

5.3.3.4 Maintaining impartiality and adhering to the facts of the case;

5.3.3.5 Key themes from disciplinary hearings.

Each of the themes is discussed further.

5.3.3.1 Disaggregation and reconfiguration of services

Within the services Monica oversees, there have been many changes. She

discusses some staff having to move frequently, the impact this has on staff and the

quality of their engagement with patients.

5.3.3.1.1 Impact on clinical staff

The impact of the continuous change leads to Monica citing a recent example: “…

people in the organisation have had five, six, seven moves in the space of three or four

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years. So in terms of continuity of service and service for the patients, it’s very difficult for

staff then to engage in that team because they’re moved around all the time, so really, as the

service closes here, they are put into another [area], then that service is at risk and then they

move somewhere else and that’s unstabilising for the staff.”

5.3.3.1.2 Changes in team managers

Monica refers to Joyce’s hearing, particularly around the lack of stability in the team

caused by continuous changes of managers and Sam’s attitude towards supervision:

“I mean a case in point was the last hearing that we have – eight or nine managers in the

space of two years. Now in terms of the team morale, what does that do? And it was a

classic case where the individual had no performance issues up to the point where these

issues were raised and then shebang, she gets the performance issues…”

5.3.3.1.3 Why do some areas in the Trust have less disciplinaries than others?

Unlike Paul, who has had to undertake many disciplinaries in his area, Monica

perceives there are less disciplinaries undertaken in her area and contributes this to

several factors: “I personally don’t have that many disciplinaries as potentially other

people/services have. I don’t know if it’s because my managers are experienced – …all my

managers are very proactive in tackling issues at the first level so if it’s sickness, if it’s

attendance etc., …they don’t let it escalate into a case where then it becomes a problem… in

my services at the managerial level there hasn’t been a great deal of turnover, …we have

remained a consistent management team and I think that’s really important.”

5.3.3.2 Training and experience of the chair

In this section, it is unclear how much of what Monica says directly refers to Paul in

his capacity as chair of the disciplinary hearing, although strong hints are made.

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5.3.3.2.1 Absence of E&D training

Paul, in his interview, reported he did not consider the ethnicity of the employee

under investigation as an issue and also due to his lack of training as a chair he was

cautious. For Monica, the training and experience of panel members listening to

cases involving BME staff under investigation is an issue: “Our disciplinary panels don’t

necessarily consist of managers who have had any E&D training, so that’s number one. …

people aren’t trained… However we get newly qualified managers who are general

managers, who come into the service and are expected to sit and chair these disciplinary

panels and make decisions when they potentially have never sat on a disciplinary panel

before and never had any training…”

5.3.3.2.2 Perceptions of the chair of the panel

In his interview, Paul reported he started chairing disciplinary hearings after joining

the Trust. Monica talks about the experiences of the chair and reveals: “The way the

disciplinary hearing runs is totally dependent on the chair. You get some chairs who are very

experienced… in conducting a hearing, whereas you get others who are very, very

inexperienced, and then again that shows in the hearing. …when they’re in the appeal…,

where I have sat with general managers who when were asked ‘Why did you dismiss the

person?’ started looking in the management case and saying ‘Why were they dismissed?’ So

the chair of the appeal said ‘But you should know, this isn’t written down, what was your

decision-making to dismiss?’ and they couldn’t answer it.”

5.3.3.2.3 Quality of decision-making

In terms of the chair making the decision about the outcome, Monica conveys: “And

it’s so important in terms of the chair of a disciplinary because they then are ultimately the

decision-maker and they will be on a standing in the employment tribunal, so if you don’t

have conviction and you don’t know the case and your rationale for the decision-making,

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then it shows… And I think a lot of it is dependent on the experience of the chair and the

panel.”

5.3.3.3 Consequences of increased administration

On a wider note, the withdrawal of administrative support has led to issues around

delays in disciplinary hearings and HR managers being unable to take preventative

measures with managers and employees.

5.3.3.3.1 Withdrawal of administrative support

Monica states the withdrawal of administrative support has had implications on

hearings being delayed and suspension of staff prolonged: “Now all the administrative

burden falls onto the HR managers and the advisers which then makes the disciplinary

process a lot longer, both for the member of staff and… management to resolve the issue,

and… well it’s not good for the organisation basically. So we may have a situation where a

member of staff is suspended for months and months…”

It was uncertain if there were any delays in hearing Joyce’s case as the IO

presenting the case was not interviewed.

5.3.3.3.2 Loss of strategic planning to minimise disciplinaries

Not working to her optimal level as an HR manager by having to undertake additional

administrative tasks, Monica conveys strategic opportunities potentially to anticipate

and curtail disciplinaries are squandered: “We then take on the administrative burden

and in terms of the impact on my role, obviously then that doesn’t free up my time to do other

things, so in terms of the strategic and in terms of looking at how potentially these

disciplinaries can be avoided by training managers in giving supervision, good induction,

good recruitment, is all lost… we don’t do enough of the preparatory work to avoid the case

of staff getting into a disciplinary in the first place.”

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5.3.3.3.3 Lack of preparatory work with managers

Tied down to administrative tasks, Monica points out preliminary work with managers

goes astray: “And it’s… HR working with managers to… do some of that preparatory work

so people are aware of their obligations. I mean we get so many… things like unauthorised

absence, sickness reporting, why are we getting those? If we did the preparatory work,

worked with staff, then maybe that could negate the need for some of these hearings.”

5.3.3.3.4 Lack of preparatory work with staff under investigation

The lack of preparation given to employees referred to a disciplinary and the

emotional impact on them are acknowledged by Monica: “As I said, I feel bad for the

staff because we just take too long and … I think our policy also … you have ‘x’ working

days’ notice doesn’t help, because at the time of the suspension, then we don’t see them for

seven working days, so you imagine sitting at home suspended for seven working days and

then you are called to this meeting and it’s really difficult. And then these disciplinaries drag

on for months and months and months and… We don’t do enough preparatory work on

preparing people of what you’re going to expect in a disciplinary…”

5.3.3.3.5 Lack of preparatory work to reintegrate the employee into the team

Monica provides some reasons why no attention is given to the reintegration process

and preventative measures: “I think it’s a resource issue. I think if we had the mind and the

mind space to think about things, then things might be a bit better, but we can’t continue with

the way, with the volume of cases that we have and the complexity of the cases we have,

working in the way we are. I mean we are paid as aides to sit here and type…”

Monica discloses the tensions when Joyce returned to work: “And never underestimate

the amount of anxiety staff go through to be put through these processes, …you sat on the

hearing last week where Sam is being questioned by the member of staff, and then you think

well, what is that working relationship and that dynamic going to be when Joyce then returns, 129

because there is all that anger, there is all that frustration against Sam…. And do we ever get

that working relationship back?”

Reintegrating Joyce and preparing the team to receive her back was overlooked as

Monica declares: “We don’t do any work on that. We take people through a disciplinary

process and they might get a first written warning and ‘Right, I am back at work.’ There is no

follow-up from that, there is no support after that, there is no reintegration into the team, the

staff are just expected to say OK, and get on with it.”

5.3.3.4 Maintaining impartiality and adhering to the facts of the case

Monica is adamant that investigations and decisions need to be based on facts: “Well

I come from the school of thought that… in an investigation you present what the facts are

and you don’t put in your opinion – it’s not up to me to say ‘They did it wrong because of

this…’”

5.3.3.4.1 Observations of IOs presenting their case

In terms of hearing cases, Monica reports some of the reactions of IOs to having their

cases dismissed. She provides an example: “Some people tend to be a bit ‘Oh, but my

case got thrown out,’ and I have always said that we’re not in the business of getting people

into trouble… it’s not a victory if you give… get a warning for a member of staff, I don’t work

like that…”

Monica continues that the employees presenting the case are looking for a

disciplinary sanction: “The investigating officer and the HR person took real umbrage to

this fact and there was a discussion. ‘Oh but we’ve done this investigation and it took so

long…’ and in supervision I said to my person, it’s not about getting a victory out of a

disciplinary, what it’s about is as an investigation, do it thoroughly, do it fairly, but the ultimate

decision rests with the panel.”

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5.3.3.5 Key themes emerging from disciplinaries

From the disciplinaries Monica has been involved in, she has noticed significant

recurring themes: “A lot of it centres around for example poor clinical practice because

people don’t have supervision, because they have high caseloads, because they’re not

trained properly, because they’re not inducted properly, because they have a series of

managers coming in and out of the department who have different methods of working, so

it’s a combination of a lot of things.”

Later on in the interview, supervision received by staff comes up again: “ It’s not just

ticking a box that you have supervision, it’s the quality of the supervision…”

In terms of specific themes relating to BME staff, Monica speaks of cultural issues:

“Sometimes there’s an issue about the cultural thing about the shouting and screaming and

aggressiveness and that might be a perception that that’s sort of cultural…”

5.3.3.5.1 Disparity between outcomes for white and BME staff

When discussing the disciplinary outcomes between white and BME staff, Monica’s

tone of voice changes as she reflected on another hearing in which she recently has

been involved: “I had a case where it’s a BME member of staff, safeguarding issue, takes a

bank card from a service user, uses it, deals the money, gambles, dismissed, a criminal

case, the whole shebang. We then have a white member of staff who takes the service

user’s bank card, withdraws money from the cashpoint, acting beyond boundaries in terms of

professional boundaries, trying to sell stuff on eBay for patients, really not acting on the

boundaries, gets summarily dismissed, gets overturned on appeal to a first written warning.”

Tones of anger at the disparity in the outcome are noted: “ I personally was shocked. I

would understand potentially that it was overturned, but not on a first written warning

because she herself admitted that she acted beyond her professional boundaries, she acted

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beyond her code of conduct, she wasn’t professional, and for it to be overturned to a first

written warning is astounding.”

5.3.3.5.2 Difference in articulation

Monica attributes the difference in the above outcomes to the articulation skills of

each employee under investigation rather than their TU representation: “ I think it’s

about good representation, but more than anything I think it’s the articulation of the individual.

I think it’s if you come across as an individual who is articulate, who can justify your actions

etc., you will get off more lightly than somebody who might not be so articulate and that’s

what I have… That’s what this particular case highlights to me, because the member of staff

who gets the first written warning is extremely articulate, she is very intelligent – no doubt

that other people are as well – but she comes across as a credible person in a disciplinary in

terms of her responses. Whereas my other individual, I think her background is

Thai/Philippine, wasn’t so articulate, was very nervous, was crying and therefore didn’t come

across as a credible person to that panel.”

5.3.3.5.3 Disproportional representation of BME staff in the disciplinary process

Monica finds it hard to measure if there is a disproportional representation of BME

staff involved in the disciplinary process: “Well I think it’s difficult to quantify. Say for

example in the forensic service where you have a make-up of a lot of BME staff, so 80–85%,

so if you have even got four disciplinaries in forensics it’s going to be BME staff because

that’s your population of staff there.”

5.3.3.5.4 Perceptions of the HR department

Monica feels there is a pessimistic view of HR within the Trust: “ I think that we are

perceived as being for the management, I think that’s the first thing, that we’re seen as kind

of the people that would only be visible when there’s something bad happening and I mean I

have had staff say to me ‘Oh God, HR are here.’”132

5.4 Summary

An observation of a disciplinary hearing, particularly focusing on an employee under

investigation, and three interviews with employees involved in the hearing have been

presented. The findings from this chapter will be discussed in chapter 7. In the next

chapter, other interviews with staff directly involved in the disciplinary process will be

highlighted.

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Chapter 6: Findings from participant

observations and interviews with

employees involved in the

disciplinary process in the Trust

6.1 Introduction

The previous chapter looked at a specific disciplinary hearing around a case. This

chapter will pay attention to the findings from participant observations and interviews

with 27 employees involved in other disciplinary cases in the Trust. For ethical

reasons related to protecting anonymity of employees, the roles and positions of

participants have been generalised as some employees could be easily identified

(See section 3.11).

The findings are presented as:

6.2 The context of the Trust;

6.3 Perceptions of BME employees in the Trust;

6.4 Perceptions of the disciplinary process;

6.5 Perceptions of employees directly involved in the disciplinary process.

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6.2 The context of the Trust

This section focuses on the context of the Trust where disciplinaries are undertaken.

Most of the findings come from participant observations presented in field notes and

interviews.

These findings come from field notes. Sixty-three days (472.5 hours) spread over

three months were spent in the Trust. All of this time was spent on the main site.

Despite making numerous attempts to contact employees and arrange participant

observation at other sites, this did not materialise. There was a lack of response from

employees on other sites to my communication. For example, emails sent and

messages left on answer phones were ignored. Some employees who responded

subtly refused to participate often citing the pressure of work or stating the

phenomenon not being an issue in their area. These localities were situated where

there was predominantly a white population and white staff group.

6.2.1 The pressure to secure Foundation Trust (FT) status

These findings are obtained from participant observations and recorded in the field

notes. The Trust has not been granted FT status on two separate occasions and is

making a third bid. At a time when the coalition government has implemented cost-

saving measures, numerous employees anxiously spoke of the Trust’s uncertain

future, particularly if its third bid fails. In recent years, there has been a high turnover

of chief executives and this has been linked to their failure to secure FT status. A gulf

and a sense of alienation between the Trust Board and the rest of the organisation

has been reported in the staff surveys and raised in some of the meetings observed

and informal times spent with staff. A common complaint that came up frequently

was the Trust Board’s pre-occupation with the financial state of the Trust at the

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expense of: the needs and poor-quality care provided to service users and their

carers; the well-being of staff delivering services on the front line at a time of rapid

changes, lack of direction and disarray. A sense of despondency, particularly from

nurses, prevailed towards senior managers who were perceived to be alienated from

the day-to-day realities experienced by front-line staff. Nurses on lower bandings and

HCAs did not convey the same anxiety and were divorced from the Trust failing to

secure FT status and the unknown potential consequences arising from this.

There is a noticeable difference to where Trust executives are based in comparison

to the rest of the staff on the main site. The Trust headquarters is situated on the top

floor of one of the highest buildings. The physical environment has been recently

refurbished with expensive carpets and new furnishings. Employees in this setting

are formally dressed and adopt a business-like approach. There are very few patient

areas situated around the Trust headquarters. Reference to this being the ‘ivory

tower’” was often heard.

The lack of stability in the Trust and heightened anxiety leading to employees not

feeling contained were attributed to poor and inconsistent leadership at the top of the

organisation. During the time spent in the field, two Trust Board executives quickly

departed without any notice. There was a lot of speculation about why these figures

had left after a new chief executive’s appointment. Among some BME employees,

there was relief about these changes with the hope that the E&D agenda would be

re-engaged with so that the needs of BME employees could be recognised and taken

more seriously. Since his arrival, the chief executive (with the chairman) has

attended several BME Staff Group meetings.

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6.2.2 Reconfiguration of services

To meet the requirements of FT status and the imposed cost-saving measures, the

Trust has been forced to look at its services and staff. Over time the number of

inpatient beds in the Trust has been reduced. Some services have been

disaggregated and reconfigured to curb costs and treat the users of the services in

the community. Patients will only be admitted to hospital if they cannot be managed

in the community. There is a constant demand on beds and a pressure on staff to

stabilise patients so that they can be quickly returned to the community and followed

up by community services.

The turnover of chief executives and the continuous disaggregation and

reconfiguration of the Trust came up in interviews. George, a white nurse, reports the

impact on front-line staff, particularly BME staff delivering treatment to patients: “I

think we have moved from feeling like we are directionless, to actually feel like we are

chaotic; I think there’s a sense of chaos, and that breeds anxiety and when people are

anxious, of course they become much more cautious, they become more divorced… unable

to contain the pressures that come from the patients, …[this] generates incidents, and you

get more complaints and of course who is at the back end of all that is predominantly BME

staff.”

Matt, a white nurse, highlights the consequence of clinicians redeployed to unfamiliar

settings after reconfiguration of services. He refers to a BME nurse: “They said the

BME manager was often not on site… What turned out was, the manager was put in an area

where he lacks expertise… he had no prior experience… and he was put there as manager.

So he was redeployed… he hadn’t chosen to work there, that was the only position in the

Trust. He was given training, he was not the brightest, he failed… He was really stressed, he

was being bullied by the consultant, he brought it up and no one did anything. And then he

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was dismissed and suspended because of all the issues in his practice and the lack of clear

leadership.”

From participant observations, clinicians often discussed the shortage of nurses in

some clinical areas and the burden placed on staff performance. Complaints of

managers being oblivious to the stresses and strains on clinicians and clinical care

being severely compromised are noted. Nurses often missed their lunch breaks and

worked beyond their contracted hours of employment. Owing to staffing issues,

managers were reluctant to release nurses for training. Poor attendance at

mandatory training required by the Trust is a common problem reported. During the

time spent in the field, the Francis Report (2013) was published. Marcia, a BME

nurse, draws a parallel to the Francis Report and in her interview raises concerns

about the staff shortage arising from the restructuring: “After the Francis Report I think

one of the key issues… was a lack of response to the internal intelligence, so people were

telling them this is happening, …services are short of staff, and all those early warning signs

should have been picked up. I could easily cut and paste from Francis, easily, in terms of

contributing factors… And this is where we come… I think we need to also think about why

people abuse? Stressed and burnt out people who won’t deliver quality services, underpaid

people. And if they work and work they won’t be developed, they won’t keep abreast with

change, they won’t be renewed, refreshed, motivated.”

To meet the pressure of securing FT at a third attempt, the Trust has had to

disaggregate and reconfigure its service. The lack of direction and chaos in the Trust

has been attributed to the turnover of chief executives. In addition, cost-saving

measures have been imposed. Alienation between senior managers and front-line

staff has been reported. Some staff have been redeployed to clinical areas where

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they do not have the skills. The shortage of staff has had an impact on the

performance of clinicians. Comparison to the findings from the Francis Report (2013)

has been made.

6.2.3 Recruitment of BME staff

This section focuses on the recruitment of BME staff, particularly nurses and HCAs in

the Trust. The findings have predominantly come from interviews. Denise, a white

nurse, compares recent African recruits to others. She states: “I think the Trust has

been ill-prepared for the waves of more recent people who joined in nursing… every few

years you will get a wave of Irish, a wave of Caribbean, but people have come with a very

Northern European cultural perspective, usually because that’s how they have been trained

at school… And now we have got people [African] whose perspective is completely different

and do not have the same reference [British education] points.”

George, a white nurse, reflects on the consequences of employing newly qualified

nurses in the Trust without being interviewed: “This goes back to a recruitment policy

years ago when people were given jobs without interviews. The people who did get through

to work for the Trust who really weren’t suited to the job, they just weren’t, but not that many,

but some of those had proved to be very problematic but I do always think that… by the time

you get to the point where you’re just going to discipline somebody, something fundamental

has gone wrong at whatever level.”

Matt, a white nurse, also mentions the newly qualified nurses who have been

recruited in the past without interviews: “We went through a period when… we wanted to

increase our quota of nurses…, we weren’t robust enough and we took people who weren’t

up for the job and didn’t really want to be nurses and I think that we have paid and still are

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paying the price for that because those nurses are now staff nurses or senior staff nurses,

ward managers, and they’re not up for the job.”

Pam, a white nurse, refers to the recruitment of African nurses: “The Trust absorbed an

awful lot of people and particularly Africans in a very short space of time… the fact that the

Trust at the time wasn’t interviewing people for the best of reasons… that was the policy that

won a national award, but I think it backfired on us in some ways.”

The perceptions and attitudes towards BME staff by nursing candidates who have

been interviewed for recent posts are conveyed by George, a white nurse, who

frequently sits on interview panels: “We’d ask them questions… ‘you’re going to be

managing staff from different ethnic backgrounds and different races, what issues come up

from that?’ And they would always answer it as a negative, as a problem to be solved. They

would never say ‘Well actually we have got these people who have triumphed over all sorts

of adversity to get here…’”

There is a perception that the Trust is ill-prepared to deal with and manage nurses

who have been appointed from different racial and ethnic backgrounds. In addition,

newly qualified nurses have been recruited without being interviewed at a time of

nursing shortfalls identified by the NHS Plan (DoH, 2000). The consequences of this

initiative to recruit poorly functioning nurses are highlighted. In recent recruitment

interviews, some candidates have revealed their negative attitude towards BME staff.

6.2.4 Perceptions of the Trust E&D initiatives

From field notes taken from participant observations, there are several groups that

look at initiatives related to E&D in the Trust. Notable groups are the Race Equality

Steering Group, Workforce Equality Group, E&D Group and the BME Staff Group.

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Apart from the BME Staff Group, it is difficult to separate and distinguish the purpose

and task of each of the other groups. Similar agendas are repeated in each group.

How these groups link together is not always clear. At first this lack of clarity is

attributed to the limited time that the researcher spent in the field. However, when

non-clinicians and clinicians (who have been in the Trust for many years) were asked

about the role, function and how these groups interrelated, they too were unclear.

An absence of clinicians was noticed in these groups. Meetings were predominantly

attended by members from one particular team and from the main site. Most

meetings were held over the lunch period. Asian snacks were provided by one group.

Those who attended forfeited their lunch break. These groups were attended by BME

staff. The presence of white staff was rare. Those who did attend were managers

and they often arrived late and sat on the periphery and near the door. They gave the

impression that they did not want to be there; this was confirmed in interviews. Subtle

behaviour towards these managers was noted, particularly around snacks served.

Food was often withheld or managers did not partake in eating it. The underlying

fraught dynamics and the emotions were never discussed and yet they had some

bearing on the meetings. In my journal/diary, I often reflected on my frustration of

attending these meetings, particularly the avoidance of the group looking at how

employees related to each other. However, some participants who were quiet in

these meetings became animated in the interviews.

Through interviews, this section focuses on the perceptions of the E&D agenda in the

Trust. Denzel, a BME official, asserts: “I think that the culture of our organisation has

perhaps got something to do with it as well, and not helped by the fact that we have had

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perpetual change and I think the culture which has to include the fact that equality is perhaps

still seen as on the periphery, and not in the core.”

With the E&D agenda, Leona, a BME clinician, emphasises: “And I think it requires

courage, leadership, not just goodwill, you need to see it within the values and principles of

the Trust, given the priority, the leadership from the top leading on it, taking responsibility and

driving it through and… you can see it trickling down through the management structure…,

but we don’t see that. It’s at the bottom of the pile.”

Despite the E&D initiatives, Gerard, a white nurse, touches on the inequalities in the

workforce: “I feel slightly uncomfortable because over the years the Trust has always

portrayed it to be an Equal Opportunities Trust with lots of policies… But sadly in practice the

workforce still feels… they are not treated fairly.”

The E&D agenda in the Trust is perceived as not improving and making any

difference to the working lives of its BME staff. Part of this is attributed to the lack of

support from Trust executive figures in embracing and applying the programme into

the core business of the Trust.

6.2.5 Perceptions towards the study

From entering to leaving the Trust, numerous behaviours, thoughts and emotions

towards the study were observed. The findings are taken from participant

observations, interviews and notes from my fieldwork journal/diary.

The reactions of these employees range from hostility to some form of acceptance

that the phenomenon needs investigation. These next comments are made by

informal participants. In terms of considering the feasibility of carrying out this

research, David, a BME nurse, states: “You’ll be lucky if anyone will touch what you are

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proposing!” The senior white clinician, Leo, expresses: “The subject is provocative and

you’re ‘shit stirring’!” Rosie, a white manager, angrily states: “What has stealing or hitting

patients got to do with race and ethnicity?” At a time when the Trust has failed to secure

FT status, Norman asks: “What are you and the university going to do with this

information? Will it be another stick to beat the Trust with?” Negative consequences of the

outcomes from the study are a concern for Michelle, a white nurse: “The findings may

be misinterpreted of the Trust being racist and discriminatory, and negative publicity may

come out of this?” Tara, a BME nurse, welcomes the study: “It would be good for the

organisation to begin to understand what is going on and why this issue keeps coming up on

a yearly basis?” Nellie, a white manager, reflects: “The Trust in their workforce report says

this needs further investigation. They now have the opportunity to do this and show their

black staff that they are taking this issue seriously and doing something about it.”

From these remarks by informal participants, several emotions and behaviours can

be elicited. All these comments were privately expressed and at times whispered

even though no one else was around.

During the course of the study, my own behaviours, thoughts and emotions were

observed. For reasons around reflexivity, a journal/diary was used to record and

reflect on bias. Personal unconscious motives for undertaking this study are

questioned in this extract: “As a migrant, is this study linked to injustices from the Raj and

Britain’s imperial past over India? Am I trying to redress this imbalance of power rooted from

the historical past?”After presenting this study to a group of white staff, to recruit

participants, I noted down my reactions after leaving the meeting: “There was a lack of

engagement. The ‘uncomfortable’ silence after the presentation makes me feel anxious and

scared. I feel deflated and despondent. I am not sure anyone will come forward… What was

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the silence about? Have I bitten off more than I can chew?”No staff from this meeting

came forward to participate in the study.

Preserving autonomy, not allowing the study to be hijacked and questioning my being

as a researcher is reported in my journal/diary: “Despite the aims of the study made

clear and ethical approval granted, I cannot understand why my methodology is questioned?

Why have I been asked to go down a quantitative route and provide ‘hard facts’ when the

statistical details provided by the Trust around disciplinaries are scant? What does this say

about the ‘politics of evidence’? On a personal level, are indirect criticisms levied towards me

about not being good enough to carry this work out? Without playing the ‘race card’ is there

unconscious factors raised about my credibility and impartiality as a BME person carrying out

a study involving BME staff? Would my perceptions be different or my motives questioned if I

was a ‘white’ researcher? Am I being defensive?”

At a couple of separate presentations about the study, I felt personally attacked and

this reaction reinforced how emotive the phenomenon was. In one meeting, it was

not clear if this was linked to the nature of the subject, something about me, what I

represented or all these factors. This was precipitated by a white clinician in a senior

position stating: “Why do ‘you’ automatically assume all white people are racists? When are

you going to look at the racism amongst black people?” The tone of voice was hostile and

angry. In another formal meeting over a Christian festive period with senior

managers, a silent uncomfortable response was observed after the study was

presented. This silence was broken by a white employee emphasising: “Too much

attention is being given to Muslim issues and Christians are being ignored.” A sense of

unease among other staff present was noted when this statement was made and the

agenda was quickly moved on to the next item.

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6.2.6 Observations of behaviours

During interactions with individuals and groups about the study, a number of

unspoken and non-verbal behaviours were observed and recorded in the field notes:

uncomfortable and heavy silences with people avoiding eye contact; rolling of eyes;

sighing; raising of eyebrows; staff turning, looking at each other and giving wry

smiles; white skin complexions turning red; individuals physically turning away from

the researcher and not engaging with the subject; quickly changing the subject when

disciplinaries were discussed; shuffling of chairs. These behaviours could not be

captured on digital recorders.

This section has been included as the responses captured around the perceptions

towards the study characterise similar attitudes expressed towards E&D issues in the

Trust.

6.3 Perceptions of BME employees in the Trust

The findings in this section come mainly from interviews. As a starting point,

comparisons are made to colonial history and the current plight of BME people in

society and how this mirrors the current position of BME staff in the Trust.

Perceptions, particularly of how BME staff are viewed and treated, tensions between

and within BME groups and the cultural working practices are highlighted.

6.3.1 Links to the historical, societal, political and personal context

Ann, a BME clinician, relates the predicaments of BME staff in the NHS to the British

colonial regime: “In the colonial regime… it served to keep the people where they wanted

the people… You could wear the master’s clothes and think ‘Yes I have a rich master, look

how well he treats me,’ but you have a master and you’re not free. And I think that for me is

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the feeling that ‘Yes you can come and work for the NHS, but don’t think that we accept

you.’”

Later, Ann claims that the position of BME people is already defined no matter how

hard they work: “It’s about positioning… I think that’s what I mean by positioning, is this

idea of ‘know your place. We can do it but you can’t do it,’ … you can’t take for granted that

you’re going to have the same experience...”

The current plight of BME staff occupying lower bandings in the Trust is highlighted

by Monica and Martina. Monica, a BME manager, briefly mentions: “ It doesn’t appear

to me that there are many people from BME backgrounds that are at a senior level in the

organisation and I think that’s probably quite significant.”

Martina, a BME administrator, observes: “There is a glass ceiling, so senior managers

are white and the lower bands are black.”

From participant observations, the lack of black role models at the senior level in the

organisation is noticeable during the time spent in the Trust. All the executive

members on the Trust Board are white. Some BME employees complained that they

do not have leading BME figures in the Trust to whom they could aspire. The data

related to the workforce highlights BME nurses and HCAs are the majority in lower

bandings.

According to Leona, a BME clinician, the experiences of some BME people in wider

society have been internalised and brought into the workplace: “Some of the stresses

that BME groups face get played out in a work environment, so… if you have grown up in a

society where you’re always the oppressed, stop and search, low expectation at school, …

you have got that self-fulfilling prophecy, sometimes it gets to the point where you can’t take

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any more and that may… come out in a work environment where you may shout or you

might say something that doesn’t necessarily go down very well…”

Later, Leona continues: “I don’t even think it’s a Trust issue, I think it’s a societal issue…

and there’s a construct that says people with black and brown skins are lesser in the sense

that they’re not as intelligent as we are, they’re not as articulate as we are…, I think because

the systems and structures are there and systems and structures don’t exist without the

people, so the systems and structures just reinforce… and drive it through”.

Denise, a white nurse, expresses that BME nurses have internalised this lack of

value and worth: “What we found was that their morale was incredibly low and they had

almost absorbed this idea that black nurses couldn’t be good nurses.”

Nellie, a BME nurse, considers the personal histories of BME employees facing

disciplinary action: “There was a consultant and we were talking about disciplinaries and in

the break she came up to me and said, in my experience the individuals that I have dealt with

were coming with baggage… layers upon layers upon layers upon layers… and if we’re not

conscious of its impact on us as an individual, as a clinician, as a carer, where does it bleed

through if we’re not mindful of it?”

Lisa, a white manager, elaborates further on the ‘baggage’ that employees carry into

the work setting: “There was sadly a lady years ago who came from North Africa and had

had a very abusive experience but was very senior – I think princess level – but is working as

a healthcare assistant – and who turned out had… infectious diseases and was incredibly

ill… she hadn’t shared any of that with us…, she died because she was so ill… Now we

found out afterwards that what she was trying to do was fund her children’s education… And

also it was around insurance, she did not want anybody to know that she was so ill because

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she wouldn’t have had the insurance which would then fund her children’s education later on

after she died.”

Gerard, a white nurse, discusses the issue of discovering information about the

outside status of BME staff and how this impacts on the team: “ I have a healthcare

assistant on one of my units that everybody looks up to, but it’s got nothing to do with work…

but outside of work he’s a very senior pastor. Now I didn’t know this, but I wanted to know

why he was getting preferential treatment for days off, time owing, etc. Now I didn’t

understand this until somebody was willing to explain it to me… So one of the most junior

staff on paper culturally is the most senior staff in the department...”

The issue of social class and how this comes up in clinical work is at the forefront for

Pam, a white nurse, who states: “Yes, for me… something about class and status…

Oddly enough it is as important as BME, but I think class exists much more really as the

heart of the issue, even between people’s own cultural groups and status…”

She continues: “If you start to talk about class you start to think about your own prejudices

towards people, what you have and what you don’t have, and whether you were advantaged

enough in life or not. And for our BME group, if they’re not British born, I guess, are not

educated here, … look upon others who may have had better privileges and easier access

and have been scornful…, it is about status and I think… it’s envy, jealousy, it’s hatred, it…

brings up the worst in people and… in some of our services where you have a predominance

of white middle-class patients, you will have that acted out more towards your black staff

group... And so there will be more disdain shown towards people… and I think often our

[BME] workforce would probably say we don’t protect them enough either.”

From these interviews, the colonial past and the social construct of BME people are

recounted to the present day. There is a perception that the position and lack of

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worth of BME nurses in the NHS have been pre-determined and reinforced by

systems and structures. According to Leona, there is a limit to what some BME

people can endure before reacting to these held and perceived injustices that can be

acted out in the workplace. Another complex picture begins to emerge involving

many strands, particularly around cultural background, life experiences and

‘baggage’ that staff brought from their outside lives into the workplace. The unknown

status of some BME employees, such as princess, chiefs and pastors outside the

workplace is made known. The complexity and context of social class are tied to the

emotions, tensions and behaviours.

6.3.2 Senior managers perception of BME employees particularly black African

nurses

This section looks at how black Africans: are perceived and treated by senior

managers; react when under scrutiny; have differences in adapting in the Trust and

have similar issues to those identified by the NMC. These findings are taken from

interviews.

George, a white nurse, refers to how black African nurses are regarded by senior

managers: “The perception of how to work with Africans and what to expect from African

nurses was I thought pretty skewed… There was an acknowledgement at the most senior

level that a lot of staff… simply don’t know how to relate to African staff… There wasn’t any

understanding of the African culture as it translates to how people work here and how they

relate to their employer, how they relate to one another, and there was a view that you

categorise all of the staff as African, when in fact of course they’re all from different countries,

they have got very different cultures, very different interrelationships with one another.”

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He continues: “When I say the Trust I mean up to Board level… and I think they just don’t

get it, they don’t get how to work with a predominantly African workforce. I think instinctively

they don’t trust them and I think they see… carrot and stick, the stick’s better.”

Gerard, a white nurse, acknowledges there is much that he needs to learn about

black African culture: “I work with an awful lot of African staff and I need to understand the

issues that exist and any tensions that may exist between some of the African staff… There

are issues that do affect their performance in work.”

How black African staff have reacted when under attack from management is closely

observed again by George, a white nurse: “The one thing that was absolutely clear…

was as a group they [black African staff] did band together when there was adversity, and

particularly when they felt they were being attacked from outside and… ‘management’. It is a

particularly African thing, they’re not going to turn round and say to you… ‘This isn’t fair, this

isn’t right, I am better than this, you should treat us with more respect.’ What they’re going to

do is they are going to withdraw. And when they withdraw, they withdraw their cooperation

and when they withdraw their cooperation you can’t get anything done…”

Denise, a white nurse, observes the difference in adaptability of black African nurses:

“I was noticing a difference between the adaptability of some of our African nurses as

opposed to others, so a lot of our more senior black nurses are from Zimbabwe; the more

junior ones, the ones we tend to have more problems with in terms of numbers of

disciplinaries, are from Nigeria, male, and that’s exactly the same as I understand from the

NMC, that most people in mental health… you are more likely to be crossed off the register,

if you’re from West Africa, black and… 40 plus, and you probably also have a gambling and

a bit of a drink problem…”

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Pam, a white nurse, also draws attention to black African nurses referred to the

NMC: “Well if you look at the NMC de-register notice, you will find predominantly those

mental health nurses that are de-registered are black Africans.”

The perceptions from these interviews highlight the unfair treatment of black staff. In

some areas of the Trust, black African staff are homogenised as one body. It is

observed that senior managers in particular do not know how to relate to staff coming

from the different regions of the African continent. Senior nurses make reference to

the disciplinary outcomes of black African nurses to the NMC.

6.3.3 Senior managers’ perceptions of relationships and tension within BME

employees

Attempts to move away from homogenising BME staff and looking at the differences

and rivalry between various BME groups are found. Gerard, a white nurse, describes

some of the changes that he has noticed in the Trust: “When I first got here, this place

was managed by the Irish… And then we slowly changed and we had more Mauritian

managers but we still had a very white top-level management. So it went from the Irish to the

Mauritian…”

The relationships between BME staff groups arose in several interviews. Pam, a

white nurse, highlights the rivalry between various groups in her service: “We have

Nigerian rivalry within tribes, we have West African/East African rivalries and we have White

European rivalries…”

Ali, a BME manager, describes the various tensions between different ethnic groups

from an investigation he has carried out. BME patients are also included in the

dynamics: “Some people had concerns about racism and it wasn’t about necessarily

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black/white, but a lot of tension between different staff groups, so there was a Mauritian

corner, a Ghanaian corner and a Nigerian corner, and tension with the patients at that time

were very largely from the Caribbean…”

From these interviews, there is a shift from the polarised position between black and

white groups. The interrelationships between various ethnic and racial groups reveal

tension and rivalry. Racism between these groups is also reported.

6.3.4 Perceptions of BME staff commitment and lack of trust placed on them

The first interviewee is from a BME background and shares her experience of BME

employees that she has investigated. The second interview looks at exclusion of

BME staff in a clinical area. Marcia, a BME nurse, who is involved in the disciplinary

process, reports: “I think culturally or socially people… the BME group here are probably

perceived as people who are not entirely committed to their job role. I mean there’s [there

are] some people, especially when I arrived, who used to work all God sent hours. I have had

a lot of cases where people have been asleep on duty, and a lot of fraud cases.”

Later, Marcia lists the attitudes she has encountered from BME staff: “Well… late

coming on duty, trying to defraud the Trust, working very long hours, conflict within the

workplace, not between whites and blacks but between blacks themselves… and

unprofessional behaviours, eating, unwelcoming behaviours, rigidity… there’s [there are]

some things I see.”

Shauna, a white nurse, tries to make sense of the resistance of some BME HCAs in

her workplace: “They never come into the Care Programme Approach because they don’t

care. It’s… ‘Well actually, have we invited them in? Do they feel that they were welcome to

come in? Have we told them they’ve got something to contribute actually?’ So it’s that

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different thinking really and making people feel that actually they are part of it. And I am not

sure we are there with that yet.”

A senior BME investigator criticises the unprofessional behaviour and commitment of

black employees. Shauna tries to understand the reasons why black HCAs are

perceived to be apathetic. She learns that they are excluded by the rest of the team.

Various interviews report the lack of trust placed on BME staff, particularly around

sickness, contracted hours of employment, their motives for working with vulnerable

people and their qualifications.

Gerard, a white nurse, highlights how BME employees are perceived: “Sickness and

absence, and finance time and time again. I think the BME side is scrutinised to find if…. is

there any way that they’re fiddling their hours, expenses … if they’re off sick they must be

working somewhere else. I don’t think the same attitude would carry to other members of

staff. So I think they are viewed suspiciously…”

Later, he continues by posing several emotive questions and challenging the

behaviour of some managers: “Why does somebody hold a belief that an African works

here for the money? Why isn’t that a racist comment? Why isn’t it institutional racist if it’s not

directly racist? Why aren’t managers using capability and performance for staff, but will allow

staff to get further and further into trouble and then progress a disciplinary – why do you do

that? That to me is a slightly sadistic thing. You have heard the phrase ‘Let them dig their

own grave’…, why would you let an individual do that, if you actually didn’t feel some degree

of animosity towards them?”

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Denzel, a BME official, indicates a similar theme: “I think there is [are] some middle and

senior managers who view its black workforce as just being obsessed with money and

earning money… But I do not think the same is applied to white staff.”

Hazel, a white manager, discloses a new computer system in the Trust which has

revealed certain information. She avoids bringing race and ethnicity into the

discussion: “…there are certain individuals, and we went through a spate of people working

whilst off sick and people just going AWOL and that was dealt with… We then had a whole

range of hearings and disciplinaries to deal with excess working, so working at the same

time, working on NHS professionals, doing back-to-back shifts, double claiming, so claiming

NHSP shifts or agency shifts, and of course that’s minimised now hopefully with NHS

professionals and e-rostering, so that will hopefully address that issue.”

Denise, a white nurse, indicates the financial motivation for nurses and HCAs from

overseas: “Obviously some clinical areas attract a lead payment… And people coming from

abroad, who may well want to send money home or be supporting people elsewhere, will

want to, as immigrants throughout history have always wanted to do, perhaps hold down a

few jobs and send money back, so why not go to the area which gives you a premium in

terms of pay, is very well staffed, so perhaps allows you to work somewhere else because

you’re not too tired at the end of that time…”

Nelson, a BME administrator, states delays in BME staff returning from visiting their

families overseas arousing suspicion from managers: “We have many cases around

people going back home and maybe not coming back when they should… and you often

hear comments, sort of raising of eyebrows and body language and so on when it’s someone

of Asian or Afro-Caribbean… that they’re pulling a fast one… My point is, if somebody was

coming back from Ireland and that happened, would that manager have the same point of

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view immediately without seeing the facts, and I don’t think they would… again it’s a

stereotype and a prejudice that they have.”

The authenticity of Ann’s (a BME clinician) qualifications is questioned as she recalls

her supervisor’s comments: “At that time I had two masters, and she was… ‘Yeah, but

where did you do it? Was it one of these made-up colleges?’ Now who goes to the made-up

colleges? Isn’t that where they send the immigrants to get their papers…, which is so

unnecessary, and discriminatory… So it’s already been decided… I have no place. It doesn’t

matter how many masters you have…”

These interviews reveal the lack of trust and suspicion from senior personnel around

the integrity and conduct of BME staff. There is a perception that BME employees

transgress their contracts of employment and qualifications are not genuine. Their

motivations are questioned. Gerard, a white nurse, wonders why some managers do

not intervene at an early stage to prevent disciplinaries.

6.3.5 Perceptions of BME employees treated unfairly

In these interviews, disparity between how BME employees are treated in

comparison to other members of staff is highlighted. Shauna, a white nurse,

differentiates how white employees are treated more informally than their BME

counterparts: “White staff perhaps are more likely to get dealt with informally; what is it

about black staff that we do not administer and deal with people in that way?”

Lee, a white administrator, speculates about discrimination: “It can only be how we

recruit as an organisation and how we develop people, in fact how we invest in people, and if

it’s neither of those two things then you’re looking at something far more sinister… but could

it be discrimination that’s happening?”

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Drawing on his interaction with BME staff involved in disciplinary issues, Tariq, a

BME clinician, recalls: “Black staff had a bitter experience… and they were treated really

badly…”

Nellie, a BME nurse, refers to the disparity between black and white staff: “ I am aware

of cases whereby individuals have raised an issue about not getting the supervision that is

required for their post in terms of client contact, so it’s affecting their training, it’s affecting

their progression where other members of staff who happen to be white are getting that…

And it’s in the getting fed up bit that there has been the danger of that behaviour and its

interpretation as aggressive.”

Peter, a BME manager, raises issues related to racism: “I think we will probably have a

mixture of people…, those who will not feel that the organisation is committed to equalities,

and as evidenced through the Staff Attitude Survey that we have, there will be people also

who have experienced harassment on the basis of their race, from service users, from staff,

from managers. There will be those people who continue up to this present day to

experience problems in the workplace, where they are being called ‘Nigger, get out!’ or

having managers slam their hands down on the table to say ‘Move, move, quicker, quicker!’

…in a very bullying fashion – these are black staff I am talking about. There will be those

who talk about issues from white managers, white staff to them, as black individuals. There

will be those who talk about issues arising from Asian staff against black staff members,

which is new…”

Disparity in treatment between BME and white staff is raised. Participants report

discrimination and harassment, but again, as Peter discloses, this behaviour

manifests within different BME groups in the Trust.

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6.3.6 Playing the ‘race card’

Examples are cited about a BME and white staff using the ‘race card.’ Marcia, a BME

nurse, describes a situation with a BME nurse who has tried to avoid accountability

after a visitor has complained about his conduct: “This gentleman [nurse] who seemed

to be coming up all the time as a problem and he said ‘Well they’re all racist and I have heard

them call me names…,’ so I explored it further with him… He kept a visitor … [waiting] for 15

minutes because this person was a bit early for visiting hours. Now is that a race thing? …

That’s not a race thing.”

Ann, a BME clinician, mentions her white manager’s comment about her applying for

a course that was oversubscribed: “I mean this manager also said to me ‘Well if they are

down on black people applying for the course, you might get in…’”

The issue of playing the ‘race card’ to avoid responsibility and obtain priority is

highlighted in these two interviews. Both interviewees are from a BME background.

6.3.7 Perceptions of cultural differences in working practices

From these interviews, the observed cultural working practices of BME staff are

discussed. Denise, a white nurse, shares an experience from visiting a clinical area

after being promoted to a senior role: “I wasn’t expecting when the first time I went on

[Ward X] as a… to have [BME] people bowing and … I was able to understand that within

what I already knew about race and culture, but there will be many white managers who

wouldn’t and would think ‘Oh my God!’”

She discusses her reaction when a BME staff member approached her for a pay

increase: “And when somebody has asked for a grade increase because they have got a big

family, which would be a very acceptable reason for asking for a raise somewhere else,

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completely unacceptable here…, a manager can respond to that. They can say ‘Oh my God,

how dare you?’…”

She also describes a situation with a BME charge nurse who was awarding herself

the best shifts: “There was one band 6 black nurse who was giving herself all of the

lucrative shifts. And when I asked her about it, her answer was… ‘But I am senior to band 5s,

so why wouldn’t I give myself those shifts? I need the money’, and so we unpicked it and

yes, that was her expectation that as a more senior person that’s what you would do, reward

yourself, which is completely the opposite from the perspective culturally here…”

Shauna, a white nurse, explores the working ethos informed by culture of a BME

HCA: “I do wonder if that goes back to the cultural and not understanding the culture… I

worked with someone on [Ward F] and staff were getting really frustrated with her… and

when we… took her aside and had a chat with her, …she said in her culture what happens is

you get your list of things to do in the morning and as soon as you have done them, you are

done for the day.”

These interviews look at how cultures are interpreted and the disparity in the level of

tolerance towards different cultures found in the Trust. Peter, a BME manager,

reports difference in culture: “Lack of sensitivity to difference… people from different

cultures, different backgrounds will act/behave in different ways, and that different people will

regard one thing as perfectly normal… The organisation is lacking sensitivity… there is not

the intelligence to recognise and deal with it.”

Gerard, a white nurse, raises perceptions around cultural differences between

manager and subordinate: “Thinking about who the staff are managed by? Are they

managed by other people from BME backgrounds or are they managed by European white

staff? But I wouldn’t say that the practice of BME staff is for me noticeably any different,…

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but I wonder if there is some level of… where difference comes in that people don’t

recognise, and sometimes I wonder whether that is less about practice and more about

different cultures and that people respond from different ethnicities to different cultures and

behaviours and ways of being, and that maybe comes out/gets misunderstood.”

In terms of the disproportional representation, Denzel, a BME official, separates

cultural difference over ethnicity: “There is a BME over-representation, but somehow

sadly some of those BME being disciplined is because they are not understood and it’s more

of a cultural awareness rather than the colour issue. They say certain things and it’s taken in

a different way and they are being disciplined, without them realising they shouldn’t say

that…”

Lisa, a white manager, emphasises the conflict between personal and the Trust’s

concepts around care:“I came across this reference somewhere that it was alluding to the

different cultural backgrounds of staff, their different takes/perspectives on caring and… how

that sort of influences their interactions with people…, there may be people who might need

support, who are coming from traditions, cultures who may view ill-health as one thing, who

have paternalistic views on matters … ‘You listen to me, I am telling you what to do… I know

best, listen.’ And the person means well but they’re coming from a different paradigm

completely and it’s… not fitting with our model…”

Pam, a white nurse, draws on communication issues, particularly around language: “I

think a big issue… is something about communication because I think often if English is not

your first language, people’s ability to express themselves, and the cultural aspect of that is

quite hard to understand, and some people’s language skills are not so good.”

The next three participants consider the interpretation of aggression from a cultural

stance. Nelson, a BME administrator, states: “Sometimes there’s an issue about, the

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cultural thing about the shouting and screaming and aggressiveness and that might be a

perception that that’s sort of cultural…”

Janice, a BME manager, gives her perspective: “I am of African descent and in Africa we

are quite animated, and… there’s [there are] some people who … are quite loud… but

people don’t understand that so they see it as aggressive…, I think it’s a lack of cultural

awareness…”

Hyacinth, a BME administrator, raises the issue of losing identity in order to be

accepted: “Our passion is seen as aggression and we have to know that we have to change

the way we are perceived, we have to be like the people who we are going to… And my

negative side took it as… we have got to change and be more white then…”

Both Denise and Shauna, who are white and involved in the disciplinary process, link

the differences of BME staff working practices to culture. Tolerance and interpretation

around the cultural differences towards behaviours and language are highlighted in

these interviews. Behaviours that might be perceived as aggressive are also

mentioned.

6.4 Perceptions of the disciplinary process

This section concentrates on the disciplinary process and is based on findings from

interviews. Attention is paid to managers dealing with BME staff, the use of

capabilities procedures, suspension of staff, the perceptions around the descriptive

statistics (from chapter 4) and the phenomenon investigated.

6.4.1 Perceptions of managers dealing with BME staff

In these interviews, there are perceptions that managers lack competency and are

apprehensive about dealing with issues involving BME staff. Lee, a white

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administrator, states: “Management practice and competency, managers finding it perhaps

difficult to deal with diversity in teams, inconsistencies in how we apply the policies, …their

confidence levels, maybe depending on who is in front of them and how they might be

presenting themselves.”

Celia, a BME nurse, suggests elements of fear and why some managers quickly

resort to formal procedures: “It could be inefficient, they don’t know how to deal with

because they really are afraid of this race factor. Some of the things could be dealt with

informally but it was left to… reach crisis point.”

Peter, a BME manager, looks at the aptitude of managers: “There’s [There are]

probably questions and issues around how competent managers feel in dealing with and

managing diverse teams. And I know that because of issues that have cropped up within

services that I have been a part of helping to resolve … where you have got issues of race,

culture, African groups, white and black staff…”

Nellie, a BME nurse, raises the capability of managers: “If white staff perhaps more

likely to get dealt with informally, what is it about black staff that we tend to fail in dealing with

people in that way?”

As white managers involved in disciplinaries, these two interviewees discuss issues

related to prejudice. Hazel, a white manager, acknowledges: “I am not naive enough to

think that people aren’t prejudiced, I suppose we are all prejudiced in certain ways…”

Lisa, a white manager, explains prejudice informed from her childhood: “I worry that

my own… because no matter how you try and escape from your background and your

childhood, you will grow up with certain values and certain things that it’s quite hard to

challenge… I worry sometimes that I have always tried to escape from that, but you worry

whether you do completely escape from it or not… when I said you can’t escape cultural 161

background sometimes yourself, no matter how hard you try, so that you don’t mean to have

a prejudice but maybe that still comes up because you can’t escape totally from who you

were and who shaped you in your early life.”

Since the Trust Board has had to review staffing resulting from cost-saving measures

imposed by the coalition government, Gerard (a white nurse) has noticed a change of

approach: “We also need to look at the reasons people are getting disciplined for… ‘Is our

threshold too low, are we jumping more into formal routes?’ Historically we would have dealt

with them outside of the process and sat down and looked at it.”

The following interviewees focus on how managers deal with disciplinary issues.

Hazel, a white manager, in her experience shares how some managers have

exhausted all avenues and have had no alternatives but to take action: “Sometimes it

is a last resort in a legitimate way in terms of saying ‘Well I have met with them, I have

explained the standards, we have supervision, we have this… and do you know what?

Nothing has changed, and we are where we are, and therefore I have no alternative but… to

go down this route.’”

She later on also highlights some managers were waiting for a chance to initiate

disciplinary action: “‘This person has been a complete pain and they have done something

that is a bit out of line and I am going to take this opportunity and go for it’…”

Peter, a BME manager, discusses managers taking the opportunity to ‘go for it’ as

described by Hazel: “I can only go on what BME people have told me because I don’t know

the detail of their cases because a lot of staff come and talk to me about it, …it appears that

the manager… has had a vendetta against them and wanted to get them out for a long time

and was waiting for the opportunity, and when an opportunity came they pushed it all the

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way.”Peter acknowledges that he only had partial representations of the facts, and

bias might have occurred as only one side of the situation has been shared with him.

Previous experience from practice in the private sector, and how this is transferred

into the NHS, might influence the haste towards disciplinary action, as Martina, a

BME administrator, points out: “If you have a manager that’s come from the private sector

and is new to the public sector, their expectation of how things are managed are quite

different, so sometimes they think well, we can quickly move to quite punitive action…”

Attention is drawn to the disparity between how managers treat BME staff and white

staff. Several perceptions of management attitudes emanate: a more formalised

approach is adopted to deal with the conduct and performance of staff; the approach

adopted ranges from having no alternative but to discipline to taking the first

opportunity to mete out disciplinary action.

6.4.2 Underuse of capability procedures

From secondary data collected, the Trust has a capability policy and procedures in

place to support staff who are underperforming. Gerard, a white nurse, expresses his

frustration that many of the cases he represents could have been avoided if

managers had used the capability and performance measures: “People shouldn’t

always be taken forward to disciplinary. There is not enough use of the capability and

performance policy made. We must have a more effective use of capability and performance

so it doesn’t progress to disciplinaries…”

Denise, a white nurse, comments on the revival of capability procedures by a recent

interim chief executive who has consequently reduced her attendance and

participation at formal disciplinary hearings: “But one good thing the previous… interim

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chief executive did is make robust the whole capability process which was underutilised…

Well I have two requests… but not as many as there used to be…”

Capability procedures to support staff and prevent them from going straight to

disciplinaries are underused until the backing from a recent interim chief executive.

Since then, Denise reports she attends fewer hearings.

6.4.3 Suspension of staff

As the disciplinary policy states, the suspension of staff is a neutral act, used as a

last resort and not a disciplinary measure. Alternatives to suspending staff where

possible need to be considered. The use of suspensions and monitoring of this by

the Trust Board are discussed. Hazel, a white manager, conveys: “We try not to

suspend unless there are serious concerns about the potential for gross misconduct.” Later

she continues: “We were monitoring that because at one stage we had an awful lot of

people who were on suspension and we were… well we still are actually monitoring that on a

monthly basis… I know they have gone down…, it was… re-emphasising it with managers…

that… suspension should be a last resort.”

Leona, a BME clinician, has experienced accusations of not complying with

employment regulations and the threat of suspension used as a first sanction: “ I

haven’t breached anything, if I had the UK Border Agency would be at my door because they

have got everything about me on their system. So if the UK Border Agency aren’t coming

and knocking down my door, then why are you [HR] trying to suspend me… it infuriated

me…”

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Although the threat of suspension was eventually dropped, Leona feels she has been

taken through a “cruel and stressful” process with no apology issued and: “everybody

has just acted as if nothing has happened, and ‘Well let’s sweep it under the carpet.’”

Gerard, a white nurse, discloses further the lack of sensitivity demonstrated by

managers around suspending staff: “Suspensions are ones in particular. I don’t think any

managers here have ever really understood what it’s like for people to be suspended – their

family life, their social life, their work life has gone…”

At a time of financial squeeze in the Trust, the economic cost of disciplinaries,

including suspensions, has not been calculated as Hazel, a white manager, states:

“No… It would be awful… because … you have a hearing, everybody gathers and

sometimes they don’t show up, sometimes you have to postpone, sometimes it goes on

longer than you think so you have to rearrange and reconvene, you have an appeal…”

Shauna, a white nurse, reports the lack of preparation and repercussions of a BME

employee returning to work after suspension and the impact this has on a team: “But

the person suspended was brought back to the ward without warning, so one day the people

turned up to work and she walks back on, having said all these things, in a safe environment,

a psychologically safe environment, and… she was there and she continued to harass them,

and now she knew that they had reported her… so they all went off sick.”

From the interviews, suspensions are not used as a last resort. Since the Trust Board

has taken an active interest in the subject, the numbers of suspensions have

declined. However, there is a perception that senior managers lack awareness of the

emotional impact of suspensions on those involved. Despite the fiscal pressure on

the Trust, the economic cost of disciplinaries to the organisation is unknown. In the

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previous chapter, Monica also refers to the issues surrounding suspended

employees reintegrating into the clinical team without any preparation and support

from management.

6.4.4 Perceptions around the descriptive statistics

Within the Trust, opinions vary among staff about the over-representation of BME

employees in the disciplinary process. These interviews highlight the difference. The

perceptions held by some senior managers that BME staff of lower bandings were

more likely to be disciplined was dispelled by the recent workforce data, as Hazel, a

white manager, highlights: “You assume it’s the lower banded people that get disciplined

more because they’re more junior and they may not be aware or they may not care or

whatever, …but actually this year’s or last year’s figures look like we have disciplined more

senior people which is interesting, and that kind of flies in the face of what people…

thought…”

Tariq, a BME clinician, observes management’s presentation of the disproportional

representation: “Senior management and all the people who were leading it were telling us

this is more of a perception rather than reality.” He continues by citing the Astar* report

that identifies the disproportional representation of BME staff: “it is not a perception, it’s

actually a reality, a day-to-day experience of BME staff … I think the reality is people who

are… maybe not of BME background… I don’t think they get it… you have to be black and

after receiving it, in order to know it…”

*Management consultants commissioned by the Trust to write a report. Several employees referred

to this report. This report was not obtained despite numerous requests made.

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Leona, a BME clinician, draws on the Delivering Race Equality (DRE) report (DoH,

2005): “All the data and the statistics collected, especially during the DRE, …clearly showed

the over-representation of BME people…”

Nelson, a BME administrator, holds an opposite view to Tariq and Leona: “ I am not as

convinced about the over-representation of BME staff in disciplinaries. There are issues, I do

believe that, in terms of race or racial and cultural awareness… but I am not sure that there

is a hidden agenda which I think many people feel, so I am not sure if I agree with that.”

Denise, a white nurse, stipulates the proportions of the number of BME nurses at

particular bandings need to be compared to the number of BME staff disciplined:

“You could say, quite rightly, nurses are over-represented in disciplinary hearings… so

looking at proportion of staff that we have that is from BME groups at the lower bands is

huge. Is it that there is an over-representation taking into account that 80% of our people at

that level are from a BME group?”

The context of the numbers of BME staff working in clinical and other areas needs to

be considered according to Monica, a BME manager: “When we talk about the over-

representation I think we should also look at the workforce itself. …I think in this team for

argument’s sake, if we say we were about 12 people there and the four people suspended,

they are all black (and they were), were the other eight white? No. I think the other eight–

maybe about four or five of them were black so it’s only minority were white, but none of the

minority white was disciplined.”

Nellie, a BME nurse, goes beyond the polarised debate and acknowledges action

needs to be taken around disciplinaries involving BME staff: “I think it started by saying

it was a perception when the survey was done and people were saying still yes, we have a

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higher proportion number of people in disciplinaries, and there is acknowledgement that what

are we particularly doing about it?”

These participants have different opinions about the apparent over-representation of

BME staff involved in disciplinaries. The debate is not polarised as a black versus

white issue particularly as Monica and Nelson, who are BME, dismiss the

phenomenon.

6.4.5 Perceptions of the phenomenon investigated

Apart from race and ethnicity, Hazel, a white manager, highlights the complexity of

the phenomenon and looks at other factors that may be associated with

disciplinaries: “If time was no object I would love to do it across the board. I would love to

say ‘Are more men disciplined than women?’ … we do not have great figures on

disabilities…, people’s sexual orientation… Are people victimised because of their sexual

orientation?”

Despite significant factors raised, the Trust does not collate figures on the sexual

orientation and disabilities of employees under investigation.

6.5 Perceptions of employees directly involved in the disciplinary

process

The aim of the Trust’s Disciplinary Policy is to: “Facilitate satisfactory standards of

conduct and performance, to encourage improvements where appropriate and to

ensure that cases of alleged misconduct, unacceptable performance or other acts or

omissions are investigated properly and where disciplinary action is necessary all

cases are dealt with consistently and fairly.”

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The disciplinary policy identifies the stages and the role of key people involved in the

process. A summary of the disciplinary stages and the employees involved in the

disciplinary is provided in Appendix 1.

Findings from the interviews with employees directly involved in the disciplinary

process are highlighted in this section.

6.5.1 Role of an IO

All investigations around disciplinaries are undertaken by an IO. Issues around

training to undertake the role of an IO are discussed in the following interviews. Paul,

a white manager, declares: “I have been trained on investigating complaints and

allegations against staff so I have been trained in that, and I have been trained in root cause

analysis which I think… that helps when you are investigating something because you look

for different things and maybe that’s where the human element comes in.”

Matt, a white nurse, similarly states: “I have had root cause analysis training with an

external facilitator of the Trust, and also the Being Open training. …which I think has been

relevant; I did some Expert Witness training.”

Gerard, a white nurse, on the other hand, has not received any formal training and

relies on informal support: “None, none. You may be able to ask a senior colleague who is

an experienced colleague who has done it before, ‘How do I do this?’ but there is no training

available…”

Drawing on hindsight, Gerard continues: “Thinking back, I think what would have been

most helpful to be able to shadow somebody undertaking that process so that you really had

a sense of what the roles and responsibilities were with that.”

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Celia, a BME nurse, who has received no formal training, explains why training

should be provided to undertake the role of an IO: “Yes. There should be training for

everyone who does it…, so it’s a consistent approach… Because the way I investigate will be

slightly different to the way someone else does it or looks at it, and perceives the situation,

so it’s a lot of disparity depending on… what kind of person you are as well. And personality

comes into it, of what you’re looking for. If you are looking to kind of push someone out, you

might look a lot harder and try and dig a lot more to find ways to do it, whereas others won’t,

they’ll just look honestly, more honestly at the situation.”

It is reported that not all IOs have received formal training to undertake investigations

related to disciplinary hearings. Celia advocates training to minimise disparity and

ensure fairness in the investigation. Some IOs look beyond the ‘facts’ for further

evidence to remove the employee under investigation.

6.5.2 Lack of training to undertake the role of chair

All disciplinary hearings have a chairperson to oversee the proceedings. Again,

issues around training to undertake this role are highlighted. The lack of training to

undertake the role of chair is a concern for Pam (a white nurse): “I think there is a huge

gap really in terms of provision for staff training because your decision can be quite life-

changing for people. And if you don’t get it right, the amount of stress, the amount of damage

that you could cause to someone’s career is quite huge. So I think that we should have

training…”

Pam continues to raise concerns, particularly around managing legal issues: “As I

have progressed in my nursing life, as I get older, older and more mature, cases are really

complex… They have lots of legal aspects to them, and one thing I have tempted to have a

conversation with, although people are in disagreement, is actually don’t most people need a

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lawyer, never mind a union rep… I sometimes think it’s more sophisticated than our

experience and training allows us to be and operate in those roles…”

Marcia, a BME nurse, also mentions the need for training: “I don’t think I was prepared

to find myself in that role defending our decision as a panel which extends beyond nursing

practice, so for that gap I think we need training to help us understand what, as a panel, you

are considering.”

The burden of responsibility, particularly around consequences, is raised by Pam,

who felt her training and experience did not adequately prepare her to undertake this

role. Marcia shares concerns of being out of her depth when asked to justify the

decision made by the chair who was unable to attend an employment tribunal.

6.5.3 Diminished administrative support

In recent years, administrative support offered to IOs has been withdrawn. Shauna, a

white nurse, discusses the repercussions of this: “Even admin support, because if you

are doing an investigation as I did on… where what I heard was so unbelievable I decided to

interview every single person… The Medical Director who has been to see me personally

twice to say ‘Where is the report…? I want the report.’ No admin support so I am typing… I

mean I went to nursing school…”

In the previous chapter, Monica also complains about the diminished administrative

support (as experienced by Marcia) and the delays in cases proceeding within the

timeframe of the Trust policy.

6.5.4 Conducting investigations

These interviews highlight how investigations are undertaken. Celia, a BME nurse,

explains distinguishing facts from emotions: “Well actually the fairest way of treating

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someone is to look at the bare facts. What I feel is neither here nor there sometimes because

what I feel can fluctuate and can change, but actually if the facts remain the same, then that

should be the way that we make judgements about whether something is right or wrong.”

Pam, a white nurse, emphasises the skills needed to facilitate the investigation and

scrutinise the information: “And actually investigatory skills are one of the key things you

do need, both in terms of being on the panel or whether you are the manager presenting the

case, partly because you need to really question and be able to look at evidence and data

and to make sure it matches and… The other skill you need is to assist the individual to talk

and not to make a judgement in an accusatory way…”

Denise, a white nurse, highlights the quality of investigation is not always factual: “My

last hearing was… for the first time it was a dismissal that I overturned because the quality of

the investigation was really quite poor and I felt that there had been a tendency to want to

dredge for statements…”

Gerard, a white nurse, reveals the process around disciplinaries is not always

adhered to: “So I think managers aren’t mentored, trained and supervised enough when

they’re going in to making a presentation…, I am interested that the process was followed

and that it was fair, that the person presenting the management side knows what they’re

doing, has got all the facts, has interviewed everybody, has got a chronology of timeline, has

done everything they need to do before we go in there, and if they haven’t, forget it, because

the Trust will always lose.”

Investigations are not always based on ‘facts’ from the findings. Sometimes

judgements and unrelated opinions are included. Hearings where the process around

disciplinaries is not followed and poor-quality evidence is presented have led to some

cases being dismissed.

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Attention is drawn to the relationship between the IO and HR personnel in preparing

the report from the disciplinary investigation. Marcia, a BME nurse, points out the

dilemma of what to include in the report: “Surely, at this stage of collecting information we

can’t start dismissing certain information as not relevant when it’s been highlighted to us. It

just needs to go into the report and let the panel make a decision.”

From this extract, Celia (a BME nurse) questions the influence and neutrality of HR

personnel: “Sometimes I get a sense from HR, …who are supporting me… to actually err on

the side of management. I get that sometimes… you’re asking me to do these things which

are sort of taking me away from being the neutral person… you are now asking me to

present information in such a way that I am saying that this person is guilty when actually

that’s not for me to say…”

Celia continues to discuss the tensions of an experience around a white member of

staff under investigation: “The other case it was a white person… the HR person, …they

were making me feel… they were being dismissive of certain information which I thought was

pertinent. So the HR person was saying ‘Well, that’s not important’ and I was saying ‘Well I

can’t say that’s not important, it’s information that we have received, it needs to go into the

report. We can’t start making judgements about whether it’s important or not for this case,’ …

this HR support person… was actually trying to create a situation where the report would sort

of not highlight the real issues that were going on for this person, … the case was a white

case.”

From Martina’s (a BME administrator) point of view, the competency and experience

of the IO determines how much input the HR representative has on the investigation:

“Again it depends on the competence of the manager who is leading on it… I may end up

stepping in and answering the questions for the manager… So a lot of the time then I can be

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seen as the person making the decision and so therefore I will be viewed very negatively. …

the manager… may say ‘HR has made me do this, we don’t really want to manage you, HR

are making you do this.’”

The neutrality of HR support in presenting the findings from an investigation is

highlighted. There is a perception that HR personnel influence what to include or

exclude in the investigation report. On the other hand, Martina highlights the HR

advisor might be forced to step in, particularly if responsibility was abdicated by the

IO.

The support from the HR department is highlighted in these next two interviews.

Pam, a white nurse, reports: “When you are investigating you have got support from HR…

I have never been in a situation where I have been left on my own to do an investigation and

to report on it without HR support, so that’s been fantastic.”

Gerard, a white nurse, states: “I think we have a terrific HR department here. I think we

do, however, lack an HR manager from a BME background for specific cases…”

Leona, a BME clinician, who was threatened with disciplinary action, discloses her

negative experience of HR personnel: “And I felt that HR are a part of the organisation

that is meant to work with the human beings, ‘human’ being the key word… There is nobody

I would go to in HR to talk to about anything to do with my personal life, or to deal with any

problems that I am having at work, nobody.”

Peter, a BME manager, echoes the view held by many BME staff: “HR don’t do the

human side of it. Amongst a lot of BME staff, the perception of HR is very… it’s a collusive

place, they are not trusted, the managers or the staff. It’s quite a sweeping statement but a

lot of BME staff are… saying ‘…I don’t trust people in HR…’”

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George, a white nurse, conveys a similar experience to Celia, above: “The staff

perception of HR is that they are basically part of the management… and I always say to

them that you are supposed to be neutral, and you’re supposed to be looking after the

interests of the staff…”

Employees undertaking investigations report support and a positive experience from

HR. However, on the other side, some employees do not trust HR as they perceive

them not to be impartial and on the side of management.

6.5.5 Relationships between the investigating team and investigated employees

The relationship between the investigating team and the employee under

investigation is further explored. Shauna, a white nurse, states: “I think if you’re the

investigating officer, they can… ‘Well if I can put my case to you and you can get it, then

that’s OK.’ But then there is the other thing you’re almost the enemy straight away.”

Nelson, a BME IO, raises his experience of investigating BME staff: “If a black person

for example comes into a meeting and they see another black face it’s phew! ‘OK, maybe I

have got a chance’… I just have the sense that they’re feeling relieved that I am there – but it

just could be me… it’s about the way that people might look at me.”

Celia, a BME nurse, describes the reactions and behaviours of a black member of

staff: “…a black person is trying by all means to get me to be on their side, to really try to get

me to understand and to present the case in such a way that it’s in their favour… And

somehow, because I am also black…, I have just had to say to them, ‘Look, my role in this

case is to get the facts, and to present the facts to the panel… to make a judgement.’”

Continuing with this case, Celia discusses her reactions of how she might be viewed.

She contrasts this experience with that of white staff being investigated: “I can see a

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sense of disappointment there. I could almost imagine them going out saying ‘Ah, this black

sister of mine! …If your own people are going to treat you like this, then hey what chance do

you have?’ …I haven’t got the sense from when I am investigating white people’s cases for

example…”

Martina, a BME administrator, comments as an HR advisor having a similar cultural

background to an employee under investigation: “I have seen a lot of West African staff

that have been subject to disciplinaries. I see… the way that they line manage, and maybe I

am more lenient towards that or more understanding… I can see the personality traits or

cultural traits that I can identify with, … I think there had been a couple of disciplinaries…

with West African staff, my response was actually … well due to the nature of the

misconduct… that’s not a cultural thing, that’s a personality issue…”

Further reactions from Celia (a BME nurse) around neutrality, emotions and

judgement from the IO towards the employee being investigated are described: “A lot

of times I think I sympathise… I understand some of the pressures that they might be going

through. I can see sometimes where things have been difficult for them – I am a nurse, I

know what it’s like to work under the front end, so I do see the challenges that they face…”

The relationships between the BME IO/HR advisor and BME employee under

investigation are highlighted. Martina recognises and is also asked to verify cultural

behaviour of staff from a similar background. Keeping ‘neutrality’ and reserving

judgements is not always easy.

6.5.6 The disciplinary panel

The disciplinary panel consists of the chair, professional lead and an HR manager.

Gerard, a white manager, comments on the ethnic diversity of the panel: “Panel

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composition has improved because it’s moved from predominantly white panels to being

more diverse…”

Denzel, a BME official, separately echoes Gerard’s perception: “There used to be…

only the white panel making the decision, judging, but now you can see, sometimes you can

have all black and BME occasionally…”

Gerard and Denzel report that disciplinary panels are more ethnically diverse with

significant improvements. These next two interviews uncover some of the motives

behind choosing BME employees from the Trust to sit on the panel hearing cases

involving BME staff. Marcia, a BME nurse, reveals: “I have been asked explicitly to sit on

a panel because I am black. I don’t know whether you have met X, she has been asked

explicitly saying ‘We want you on the panel because you’re black…’ But I was there to

assess whether this lady from Namibia… I was asked to help with the competency.

Interestingly when we went to do the competency assessment, she didn’t even relate to me,

she didn’t even want to talk to me… I do not know what the Namibian culture is. We share

the same shade of skin, that’s almost about all… it was bandied there in the hearing, ‘You

are here to provide a cultural perspective.’ I mean for a nurse not to be able to understand

the medication procedures is not a cultural issue, it’s a competence issue…”

Nelson, a BME administrator, discloses: “We were the decision-makers so it was down to

us… Once the case had been presented by the investigating officers, it was down to us to

decide whether the allegations were proven… It ended up that we did dismiss this black lady.

And the two people who were charged with, if you like, dismissing her, were black… And that

case, probably more than any other, made me actually reflect, has this been done on

purpose or deliberately to sort of allay any future accusations of race, racial bias or racial

discrimination? Somebody black has been dismissed by two black people… it can’t be

racist.”

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In the first interview, sharing the same skin colour is equated to the assumption that

these two people share the same culture when this is not the case. The other

interview reveals two BME panel members are specifically selected for a disciplinary

panel involving a BME employee being dismissed. Nelson speculates on some of the

underlying reasons.

Perceptions of a fellow panel member’s attitude are revealed in this interview. Celia,

a BME nurse, observes: “The one that really comes to mind is ridiculous – I don’t

understand what this guy is saying…, this is my panel member saying… and you can see

them switching off. So this person is trying to explain in whatever way that they can, with the

language barriers that they might have, and you can see it in the discussion where they’re

being cut off in mid-sentence, so they haven’t quite finished explaining what they’re saying…

And I am thinking well, this is about someone’s life is at stake here, can we not allow

someone to express themselves so we can try and understand where they are coming

from?”

Celia exposes the lack of tolerance and perseverance from a panel member to allow

a BME employee under investigation to give a representation of their case.

6.5.7 Role of the professional lead

Each disciplinary panel has a professional lead that comes from the same discipline

as the employee under investigation. Denise, a white nurse, describes her role as a

professional lead: “The person who is sitting before me is a nurse who I am judging her on

the quality of the investigation and what the impact is on practice and whether they can

practise again safely as a nurse. My prime consideration always has to be safety of the

public.”

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As a professional lead, Pam (a white nurse) considers conscious and unconscious

motivating factors: “Yes, so whether it’s motivated by racism or motivated by … a difficult

relationship because you don’t like somebody of a particular cultural group… when I am on

the advisory panel, certainly in the management case, I do look at those types of

relationships in a … conscious and unconscious way because I think they’re very important

influencing factors.”

Celia, a BME nurse, considers her reactions when listening to the conditions and

pressures placed on nurses: “It’s very emotive when you sit there and you hear what

nurses are doing, how they are working over and above what’s expected of them… I sit there

and we are making such harsh decisions – that always … really doesn’t sit comfortably with

me. If someone has crossed the line, …I always find it… very difficult because it’s… what I

am presented with, this case, doesn’t tell me about the individual nurse in total, about their

whole nursing career in what they have given…”

An insight is given into the role and position of the professional lead in disciplinary

hearings. There is some acknowledgement by a nursing professional lead of the

conditions and pressures faced by nurses on a daily basis. Deciding on the future of

the nurse under investigation without knowing all their experience and commitment

presents a challenge for some professional leads.

As another panel member, Gerard, a white nurse, gives his perception of the

attitudes of professional leads: “My experience of professional leads, it’s almost as though

they want to come up with the harshest sanctions for their own members than anybody

else… It’s almost as though you must beat your staff up… more than anybody else to prove

your independence…”

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From Gerard’s experience, the sanctions recommended by professional leads from

the same discipline appear to be disproportionate.

Denzel, a BME official, gives his perceptions of the disciplinary panel: “I don’t think all

managers are trained into handling disciplinary… I can see it straight away when I look at the

panel… and I think ‘Oh, I think I may have an easy ride,’ or ‘Oh, I will have a tough ride.’”

He explains: “An easy ride is if they understand and I can manage to persuade them to see

our point of view as to why we made a mistake or where we went wrong, and please try to

see it in the context of the whole case. A tough ride would be… if they say ‘Theft is theft, I

don’t want to know anything else,’ or ‘You were sleeping, full stop.’ It doesn’t matter what the

staffing level was, how tired you were, what your caseload is, …that is a rough ride…”

Denzel could pre-judge the proceedings and outcome depending on the personality

and flexibility of panel members who are present at the hearing.

6.5.8 Perceptions of TU representation

All employees who are under disciplinary investigation have the right to be

accompanied by a TU representative at all stages of the formal procedures. This is

on the proviso that they have joined a TU before the investigation. Gerard, a white

nurse, reveals his frustration about the quality of TU representation that he has

witnessed: “The thing that irritates me is when people are clearly not being represented

well, you know they have only just met them or the union rep is sitting there from whichever

department and doesn’t know anything about the case…”

Celia, a BME nurse, appreciates the depth of knowledge provided by TU officials

about the wider context and failures of systems that might be particularly unknown to

the panel: “The union rep… usually understands the Trust’s workings, so… they can make

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sound arguments about mitigating factors. …they might say ‘Well actually I know that within

this team, …they have had special measures’, which is something which perhaps me sitting

on the panel wouldn’t necessarily know. But they’ll be using that information to try and sort of

build a case for this person, that actually perhaps they have been left in a situation where the

Trust hasn’t fulfilled some of its responsibilities because actually if a team is totally failing,

how can you then pull out one individual member of that team and say you’re not

performing?”

Hazel, a white manager, highlights the position of TUs against management: “I think if

you talk to unions, they will probably say that HR are part of management and therefore we

are not that objective… In a public forum, the rep will take a certain role which we accept

that’s what they do… but sometimes the rep doesn’t always behave appropriately.”

George, a white nurse, questions the attributes and standing of some TU officials in

their presentation and representation of employees under investigation: “Within our

Trust some reps go all guns blazing but… I don’t think they always give the right advice… I

know that the Trust don’t [doesn’t] take some reps seriously… at a senior level. So when

somebody is in deep trouble…, they’re not on their own but they’re not particularly well

protected.”

Lyn, a BME employee, who had a disciplinary action initiated against her, expresses

her anger about inadequate TU representation from the BME official: “‘I [the TU

official] just wanted to say I could never have produced anything like this’ which didn’t help

me because I actually felt very angry. I just thought you’re a union representative and you’re

telling me that you couldn’t produce this, so I was really quite annoyed.”

Denzel, a BME official, speculates how his role might be perceived: “I have two

camps… There are those who will be really, really grateful to you and say ‘Thank you very

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much. If it wasn’t for you I wouldn’t have been able to do this or that and I appreciate all your

help.’ Sadly there is still a section of staff who see me and may think… ‘you are part of the

management, we don’t know whether to trust you, whether you’ll listen as part of

management, we are all in together’…”

A conflict of interest around roles could emerge, as described by Gerard. TU officials

are able to provide further details unknown to panel members about the context and

the setting. Opinions towards TU officials are centred on how they present the case

for the employee under investigation and the outcome of the hearing.

6.5.9 The employee under investigation

Over a period of time, Shauna, a white nurse, has noted the variance of the

behaviours exhibited by BME staff under investigation: “A whole range of behaviours

really from people who are so upset and genuinely anxious and worried and allegations were

made against them – they just can’t believe it. And you can tell that it’s really had an effect on

them, right through to someone who is just sort of really quite blasé about it. And with one

case I really felt… even though the person had been suspended, they didn’t get the enormity

of what was happening to them … and maybe that was just how they were coping with it…”

Lisa, a white nurse, observes the capacity of staff under investigation to reflect,

demonstrate insight and accept responsibility has some bearing on the outcome: “I

think it makes a difference when staff take responsibility… for what has happened, so for the

people who show remorse, show insight…”

Celia, a BME nurse, gives some understanding of defensive behaviour and considers

some of the underlying factors that might motivate this behaviour in the disciplinary

hearing: “Different people respond in different ways, and somebody could be seen as being

defensive because they’re anxious. I think when somebody is put on the spot… you want to

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articulate and defend your position or explain what it is you do, and if you feel then that

you’re not being heard, then you might get a bit more anxious, your voice might become a bit

more abrupt – not because you’re being abrupt but the situation and the circumstances

influence that. …I certainly have seen a situation where someone interrupted one of the

panel members as they were asking a question and somebody then interrupted them before

they finished, and that created some tension. And one of those instances was somebody

from a black and BME background who interrupted. I think it was because they wanted to get

their point across, so they could see how the question was developing so they sort of tried to

answer quickly.”

Lisa, a white manager, tries to empathise with BME staff attending the disciplinary

hearing: “I don’t know what it’s like for the person where the allegation has been made, what

it’s like if they feel they’re from a different cultural group and they’re sitting in front of an all-

white panel say.”

Several behaviours are noted about the employee under investigation. The capacity

of the employee to demonstrate awareness of the concerns raised is deemed

significant by panel members. The chair acknowledges the impact of the stress of the

hearing on the behaviour of the employee having to account for the issues raised.

6.5.10 Mitigating circumstances

Extenuating circumstances for the conduct and clinical practice that are under

investigation is considered in these interviews. The circumstances are related to the

working context, professional support, supervision and personal situation.

Marcia, a BME nurse, describes the context of the work environment and specific

factors that might have influenced the conduct and practice of staff under

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investigation: “An increased workload… environment, resources, staffing levels, all of those

things are relevant…”

Celia, a BME nurse, reveals mitigating circumstances for a nurse who has been

suspended from her duties: “And so the sickness level was up, people were demotivated,

probably stressed and burnt out. There have been issues about poor practice on the ward.

Now I am investigating and people were suspended in relation to that poor practice, and

when I investigated I found that they’re often short of nurses, obviously people don’t want/like

working on the ward, and people did their very, very best and sometimes the standards were

short of what we would expect because of the circumstances. Somebody was observed to be

restraining inappropriately, but she was the only nurse… there was [were] only two nurses

and a patient that kicked off, so she did the best she could. Somebody who walked in the

ward observed that and the nurse was suspended.”

Paul, as a white chair, provides a space and an opportunity within the hearing for

employees to highlight anything extenuating contributing to their poor conduct and

practice: “I try and make space for it in the hearing, to understand the mitigating

circumstances, so if you have got a single parent who has been putting masses of extra

hours in because of their income issues or… so at least try and weigh what the mitigating

factors are.”

Lisa, a white manager, reports some shocking mitigating circumstances for

employees breaking the law on employment hours: “There was a BME woman that I

think she had worked something like 70 days on a roll without a break… She brought some

mitigating circumstances. Her partner had left her in the lurch with lots and lots of debt that

he had… and she was trying to work it off… So she did bring some mitigating circumstances

to that one which helped her cause.”

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Lisa also takes into account the mitigating evidence in the context of the employee’s

attitude, which has some bearing on the outcome: “I met an ex member of staff some

while back, and I think she has probably gone on doing what she did, if she can get away

with it in other hospitals and she was quite defiant about it, she didn’t see that… ‘Well I am a

good nurse and… the fact I am working 20-hour shifts effectively is not a problem.’ So she

was someone that actually dismissing her was the right thing to do because she is not taking

it on board.”

Matt, a white nurse, reports a common subject arising at the disciplinary: “ I mean the

theme that emerges is the lack of supervision, …appraisal, objectives are not articulated. …I

mean there’s no role modelling…”

Marcia, a BME nurse, refers to managers and supervisors ‘turning a blind eye’: “With

better supervision, candid conversations… – if those happened earlier we would see less

people come to the disciplinary because what I think happens, the behaviours perpetuate,

mainly because they haven’t been addressed. …I see somebody who has really done

something that’s really disciplinable, but when you look back and I say ‘OK, tell me about it,

how did you come to this, how have you arrived here?’ And I often find, they say ‘Oh well,

since 2002 this has been happening.’”

The professional support given to people under investigation at a hearing needs to

be formalised according to Hazel, a white manager: “Routinely we should be asking

managers who are preparing a management case at a disciplinary to give us supervision,

appraisals records, one-to-one records; it should be part and parcel of the written case… I

am a firm believer that more and better supervision would prevent some of them (not all of

them)…”

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Gerard, a white nurse, discloses supervision and appraisal are raised by the defence

team: “The truth will always be out and the number of cases that come before disciplinaries

where I will say ‘Was this identified in your last appraisal?’ ‘I don’t remember my last

appraisal.’… As a union rep, I would attempt to dismiss any disciplinaries where no

supervision has taken place…”

Denzel, a BME official found in his investigations: “In my opinion at least 50% because

people were not supervised…, issues were not identified through supervision… If I were

subject to one of these disciplinaries because my manager hadn’t heard me…, I would be

making a grievance against them for not identifying my shortcomings or weaknesses at a

very early stage…”

6.5.11 Reactions to disciplinary outcomes

Regarding making judgements, Denise, a white nurse and appeals panel member,

stresses the decision needs to be based on facts incorporating E&D practices: “The

chair need[s] to be seen to make decisions on the basis of fact, transparent facts, not

supposition and I think that’s particularly important when some white people, not all, some

white people are cautious about making decisions that involve BME groups. …they need

to… have confidence that they are doing the right thing that is based in good equality and

diversity practice, and is transparent and defensible to the Trust staff and beyond.”

Having been in both roles (as an IO and panel member), Celia(a BME nurse) talks

about an experience as an IO when she disagreed with the panel’s decision: “ I mean

there’s a case that I did which was about nursing practice and I seriously felt that this BME

person was working way, way beyond par, it was something that I wouldn’t even have

expected a student nurse not to get right, and I had huge concerns about that person’s ability

to deliver safe care. And when I presented the case to the panel, the outcome was that well,

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actually this person should be downgraded and put on the ward, and I was thinking well

actually putting them on the ward, they are still unsafe…”

Celia, a BME nurse, who has also been a professional lead, expresses her frustration

around the inconsistency of sanctions applied around similar cases: “ I suppose my

main frustrations with sitting on the other side is my panel members in a way, because there

are times when I have sat on the panel and I have thought my colleagues are not very

appreciative of … Well they have got varying standards of sanction, and I have often

wondered why are we giving certain sanctions in this case, and yet two weeks ago when I

was in a similar case, the sanction was not as severe, what is that about?”

Shauna, a white nurse, discusses the sanctions given for poor administrative tasks

being more harsh than for a failure to provide basic nursing care to patients: “I am

talking about where I was frustrated sitting on the other side and presenting this case and

clearly someone can’t do basic nursing care, I think a month or two months later I was sitting

on a panel, the case was being presented, the nurse has not documented…, the nurse has

used language which perhaps can be misinterpreted – not because they intentionally intend

to do that but there’s a language barrier…”

Part of making a properly considered decision involves incorporating, where

necessary, E&D practices. It is reported that white chairpersons of hearings are too

cautious making decisions involving BME staff. Outcomes for similar cases are

inconsistent. Cases involving legal and bureaucratic issues are treated more severely

than cases involving poor basic care.

Denise, a white nurse, expresses the differences in outcomes: “It’s been one of my

beef for quite a long time… you would expect to look to see that the same penalty is being

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applied across all cases… I think the Trust hasn’t done as much as it could to look at…

What’s the penalty being applied here? Are we being fair across professions?”

Celia, a BME nurse, makes another brief comparison: “I mean I sit on panels where…

the two cases that I gave as examples actually were one… the person that I felt should have

been fired was a white person, and the person that I felt was being harshly treated was a

black person… it appears to me as if there’s always… much, much harsher outcomes for

BME staff than there is for white counterparts.”

There is disparity in outcomes for similar cases and BME employees are perceived

as being treated more harshly than their white counterparts.

Denzel, a BME official, notes the reasons for the disparity of outcomes results from

articulation, the capacity to reflect on the incident and showing remorse: “That’s where

the cultural thing and the communication comes in. Some of my BME staff gets a harsher

punishment than a non-BME, because the other person may be able to articulate, and then

most of the times the panel want an acknowledgement from the member to say ‘Look I did

something wrong and I won’t do it again’. A white person is better to articulate that better –

this is my experience…”

Shauna, a white nurse, mentions racial bias fleetingly in addition to articulation skills

and demonstrating remorse: “It’s just maybe… just a racial bias thing… perhaps cases are

not given a fair hearing as people are frustrated with language barriers… and therefore…

don’t get to the bottom of things, or they just get frustrated with not understanding someone’s

dialect of whatever. … Usually white counterparts, they are more articulate, they can present

their cases quite clearly and succinctly and to the point. The manner in which they come

across, you could say they are quick to apologise for things that they have done wrong.”

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The outcome from the hearing in some cases depends on the skills of the employee

under investigation to articulate, demonstrate insight and accept responsibility when

transgression has occurred. There is a perception that white staff could demonstrate

these skills better than their BME counterparts.

6.6 Conclusion

Table 1 provides a summary of the key themes from the findings. The findings from

the descriptive statistics, observations and interviews from a disciplinary hearing and

this chapter will be summarised and discussed in the next chapter.

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Table 1: Summary of the key themes

The Trust Perceptions of BME employees in the Trust

Perceptions of the disciplinary process

Perceptions of employees directly involved in the disciplinary process

The pressure to secure FT status Links to the historical, societal, political and personal context

Perceptions of managers dealing with BME staff

Role of an IO

Reconfiguration of services Perceptions of BME employees particularly black African nurses

Underuse of capabilities procedures

Lack of training to undertake the role of chair

Recruitment of BME staff Perceptions of relationships and tensions between BME employees

Suspension of staff Diminished administrative support

Perceptions around the Trust’s E&D initiatives

Perceptions of BME staff commitment and lack of trust placed on them

Perceptions around the descriptive statistics

Conducting investigations

Perceptions towards the study Perceptions of BME employees treated unfairly

Perceptions of the phenomenon investigated

Relationships between the investigating team and investigated employees

Observations of behaviours Playing the ‘race card’ The disciplinary panel

Perceptions of cultural differences in working practices

Role of the professional lead

Perceptions of TU representation

The employee under investigation

Mitigating circumstances

Reactions to disciplinary outcomes

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Chapter 7: Discussion

7.1 Introduction

This chapter discusses the results from the previous three chapters. A summary of

the findings is presented in Table 1 (p191).

7.2 Discussion of the findings

Focused and critical ethnography was undertaken to explore why there was

disproportional representation of BME employees in the disciplinary process in an

NHS Trust. To understand this phenomenon, admittance was needed to a Trust

willing to allow an ‘outsider’ to investigate the culture and obtain access to the

‘multiple realities’ on a sensitive and ‘taboo’ subject in the natural setting (McGarry,

2010).

My literature review revealed a dearth of studies that had used ethnographic

approaches to explore these issues. Participant observations were carried out within

an NHS Trust and employees directly involved in the disciplinary process were

interviewed. In addition, a disciplinary hearing was observed.

The discussion is divided into three sections: the Trust; BME employees;

disciplinaries. This reflects the presentation of the findings in the results chapters.

7.3 The Trust

In this study, to understand the disproportional representation of BME employees

involved in the disciplinary process, the context and the culture of the Trust was

considered. Unstable leadership, at a senior level, within the Trust and continual

disaggregation and reconfiguration of services were issues that appeared to 191

contribute to the disproportionate representation of BME employees involved in the

disciplinary process. To a certain extent, these issues were reflected in the literature

reviewed. The RCM (2012) found that midwives were over-represented in disciplinary

proceedings. Their report recommended investigation of organisational culture,

management practice and leadership in the NHS. Carter (2000), Cooke (2006a and

b), Archibong and Darr (2010) and Stone et al. (2011) highlighted that organisational

factors, management practices and styles contributed to poor standards and

discrimination.

7.3.1. Leadership in the Trust

My findings highlighted the fact that the Trust has failed to secure FT status. Two

bids had already been turned down and a third application was in the process of

development. If that were to fail, the future of the Trust in its present form is

uncertain. To achieve FT status, the Trust needs to demonstrate that it is financially

viable and legally constituted (DoH, 2008). Added to the Trust’s burden, the coalition-

led government in 2010 imposed a £20 billion saving cost on the NHS (King’s Fund,

2011). Interview data with participants and data from my observations indicated that

strong, stable, consistent and effective leadership from the chief executive with the

support of the Trust Board was needed to steer the Trust to FT status. Analysis from

this study implied that this has been weak from the top of the organisation.

During the past eight years, there has been a high turnover of chief executives. The

continual change of chief executives has led to uncertainty and instability in the Trust.

With the preoccupation to secure FT status, chief executives and the Trust Board

have been unable to take a Janus-like position and have lost touch with the day to

day experiences of employees at the grassroots. This study found a gulf between

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those at the top of the organisation and clinicians delivering clinical care. From

participant observations, staff surveys and interviews a sense of cynicism, a lack of

trust and confidence towards the Trust Board and senior managers was found

particularly amongst nurses.

The uncertainty of the Trust’s future and the lack of its clear leadership came up in

the interviews. This has had a destabilising impact on the workforce, which has

affected staff morale and their motivation. Initially, Trust employees have tried to

adapt to the prerequisite of each new chief executives who have been in post for

brief periods. However, some employees reported that they have disengaged to

adapt to the frequent changes of chief executives. Participants also recounted feeling

despondent, angry and tired caused by the lack of direction and inconsistent

leadership.

7.3.2 The impact of disaggregation and reconfiguration on services and staff

To make itself financially viable and meet the changes in care and treatment, the

Trust has had to review its services and resources particularly staff. As a

consequence of government policies (Modernising Mental Health Services: Safe,

Sound and Supportive, DoH 1998; The National Service Framework for Mental

Health: Modern Standards and Service Model, DoH 1999; The NHS Plan, DoH 2000;

The National Service Framework for Mental Health: Five years on, DoH, 2004),

treatment has moved from inpatient to community settings and some services have

been disaggregated and reconfigured to accommodate the changes. With the

number of inpatient beds being reduced, more emphasis has been placed on treating

patients in the community. Patients are only admitted to inpatient settings if they

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cannot be safely treated and managed in the community. Once stabilised, they are

quickly discharged and picked up by services operating in the community.

This study found that the changes have led to much uncontained anxiety felt across

the various tiers in the Trust. This has impacted on how employees undertake their

roles and responsibilities particularly in caring for the users of Trust services. Reports

from the CQC and Commission for Health Improvements (CHI), which no longer

exists, have highlighted poor-quality care in some clinical areas in the Trust. The

level of dissatisfaction experienced by some employees has been reflected in the

Trust’s NHS Staff Survey and BME Staff Survey. In addition to these reports and

surveys employees expressed in their interviews that they have been ignored, not

been valued and supported during these tumultuous changes.

The economic pressure has forced the Trust to review its workforce. Posts and

teams have been disbanded or changed. Some clinicians have been downgraded,

redeployed, made redundant or undertaken the mutually agreed resignation scheme.

Redeploying staff into unfamiliar areas was raised as an issue in this study.

Preparing teams for the arrival of an employee from a service that has been closed

came up in the interviews. Negative consequences when staff were moved without

proper consideration was reported. Matt highlighted this issue when he reported a

BME ward manager was redeployed to an unfamiliar clinical area where the team did

not want him. The consultant questioned the clinical skills, competency and

performance of the BME manager who in turn felt bullied by the consultant and the

team. Relationships became fraught and strained. The BME manager was involved

in a serious incident. He was suspended and, after his disciplinary hearing,

dismissed. Duffin (2003) highlighted the lack of competency among BME staff might

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not be the fault of the nurse and may result from poor supervision and minimum

support. This case also focuses on the need to pay attention to teams that are

resistant to accepting redeployed employees into their services. Cooke (2007)

described how incompetent ward managers were scapegoated particularly when

senior managers ignored the wider systems and processes leading to the failings.

Stone et al. (2011) reported mistakes did not happen in isolation and systems in the

NHS were not designed to prevent errors from happening. From this study it is

difficult to know how much thought has been given by senior managers around

protective measures to prevent mistakes from happening when services have been

reconfigured to curb costs in the Trust. Murray (2005) emphasised context where

employees’ work needed to be analysed and organisational and management factors

should be considered along with individual ones.

Staffing levels, particularly in nursing, have been affected during the reconfiguration.

In the interviews, managers reported that nurses have bigger caseloads and are

doing more with fewer resources and working over and beyond what is expected

from them. Both Marcia and Celia reported this when looking at the mitigating

circumstances surrounding disciplinary investigations. Comparable findings were

also found in Cooke’s (2006b) study.

7.3.3 Management in the Trust

A mixed picture of how white managers and BME staff relate to each other is

depicted in this study. Senior managers were perceived to have a “skewed” picture of

black African nurses and HCAs. BME staff, particularly those in lower positions and

on the front line, speculated that white senior managers lived in white affluent

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suburbs and did not come into contact with BME people outside the workplace. As a

consequence they did not know how to relate to this group. These managers, as

highlighted by Matt were perceived to distrust particularly black staff from Africa and

took a “stick rather than a carrot” approach when managing this group. BME staff

were perceived to be treated more harshly and unfairly.

This study found the pressure and demands placed on managers in the current

climate are immense. Sam shared his experience of being redeployed as a team

manager to a clinical setting. There had been a quick succession of six managers.

He found staff paid more attention to non-work related issues than providing good-

quality patient care. Four BME staff have been disciplined for poor conduct and

performance since his arrival. Sam could not understand “how the hell has this been

allowed to go on for so long? Some managers let them get away with blue murder.

They [staff] were allowed to get away with it.” Part of the ‘getting away with it’ was

owing to managers and members of the team not challenging poor conduct and

performance. King and Wilcox (2003) and Archibong and Darr (2010) conveyed how

managers found it difficult to deal with disciplinary issues because of not having the

skills and confidence to deal with conduct and performance issues.

When managers confronted inappropriate and unprofessional staff behaviour, this

could be daunting. There was trepidation particularly when managers were

threatened with grievances and accused of bullying and racism. Marcia, a BME

employee, reported the ‘race card’ being played in some instances where she has

challenged the conduct of BME staff and investigated disciplinary cases involving

them. Sam, also a BME employee, has had a grievance taken out against him by

some members of the team when he highlighted and addressed the issues of poor

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performance and conduct in his team. He was accused of been a racist. Despite

being cleared, the stress and strain of the allegation impacted on his health.

Line management, supervision and appraisals did not always collaborate to deal with

performance and conduct issues. Where there was an absence of collective

responsibility, managers could end up dealing with the stressful situation without any

support. The case mentioned earlier of a poor-functioning team with issues around

staff misconduct in a clinical area that has been put on the ‘At Risk Register’ for the

second time raised many concerns. It is unclear what measures the Trust took first

time round to deal with at risk issues and why these strategies failed. Further

questions from this study can be raised: why did the wider team not challenge the

staff conduct and performance in the context of the clinical work? If staff were

frightened, why did they not report bad practices to managers outside the unit? Or

have poor practices become normalised and a part of the culture in the clinical area

until a robust outsider came and exposed the malpractices? Why did professionals

ignore the code of conduct laid down by their regulatory bodies? Clinicians trained to

treat vulnerable and sick patients did not always behave professionally. Managers

and colleagues observing this behaviour, as Heffernan (2011, p. 1) stated, became

‘wilfully blind’ by “denying the truths that are too painful and frightening to confront.”

This concern was expressed in the Francis Report (2013). Marcia, investigating a

nurse accused of misconduct and poor clinical practice, stated she could quite easily

“cut and paste” from the Francis Report.

7.3.4 Changes to organisational culture

The emic approach provided insight to the culture of work settings (Fetterman, 2010).

This study found the influx of continuous change had some bearing on the context

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and the culture of the Trust (Goodson and Vassar, 2011). To accommodate the

reorganisation of the Trust, Monica, a BME manager reported some employees had

been moved many times, that made it difficult to engage and integrate with the team

and develop meaningful therapeutic relationships with patients. Team cohesion and

morale was affected. This had a destabilising effect on the employee, the team and

the continuity of care delivered to patients.

As this study found, changing the culture of a clinical area where poor practices have

been exposed could be challenging and slow. Getting employees to change their ‘old

way’ needs careful planning and monitoring as Leona feared there is the potential to

replace one collusive system with another. Bringing new staff into a clinical area

where staff have been sacked and removed can create splits and segregation in the

team. Sam revealed the new staff who joined his team sat at one end of the room

whereas the existing staff sat at the other. The lack of trust and acceptance created

tensions that made it difficult for integration and team cohesion to happen. If tensions

around the splits are not worked through, patients can get caught up in the dynamics

or might exploit the divisions. For patients diagnosed with borderline personality

disorders, this can be a prime setting to play staff off against each other (Bateman

and Fonagy, 2005).

7.3.5 Patient care

Patients can become the recipient of staff frustration. Not all patients are appreciative

of the treatment of care received and can criticise staff. Sam described the patients

who used the services he managed as having severe and enduring mental health

issues with complex and traumatic histories. According to Sam, not all nurses wanted

to work with these patients as they presented huge risks. Presentation of their

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behaviours can be challenging and result in poor therapeutic engagement and risk

management. The lack of good-quality clinical supervision, as discussed in the next

section, can add to the problems (Duffin, 2003).

Patients who do not respond positively to the treatment can make clinicians feel

inadequate and frustrated. Working with this type of patient can be unrewarding.

Family, carers, relatives and friends can also become critical, blaming and angry

towards staff when their loved ones are not cured of their ailments. Consequently

complaints can be lodged (Cooke, 2006b). Hostile and angry feelings from staff can

be projected and displaced onto patients, colleagues and managers who are or

maybe perceived unsupportive. Similar behaviour in patients towards staff is mirrored

as highlighted by Matt. Overt or subtle retaliatory behaviour can emerge if the

situation is not properly managed. At the extreme end, patients attacking

nurses/HCAs and nurses/HCAs hitting patients occurred in the Trust. These issues

came up in the interviews. Pam found white middle class patients showed more

disdain towards BME staff who in turn felt unprotected by the Trust. Alistair

mentioned nurses physically hitting and neglecting patients.

Speculation about BME staff not born here and discriminated against, having to work

harder, denied opportunities to progress and struggle economically, in comparison to

patients and employees with better privileges are considered by Pam. In addition to

these factors, Pam also reflected upon the constant pressure to deliver services at

times of continuous change, uncertainty, staff shortages and unsupportive

environments taking its toll on BME nurses and HCAs who are on the frontline in

providing care. The repercussion in the form of resentment, jealously, envy and

hatred of not been appreciated and not having the same advantages is considered

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by Pam during disciplinary investigations. Alleyne (2005) highlighted there is a need

to engage with unpleasant strong emotions in addition to looking at cognitive and

prescriptive approaches. This emotional aversion is also taken into account by

Obholzer and Roberts (2003). Healy and Oikelome (2006), linked social class to

BME employees and Dhaliwal and McKay (2008) looked at class and related this to

working experience of BME female nurses in the NHS.

In addition to Sam’s perceptions of staff “turning a blind eye” and Pam’s claim

mentioned above, Marcia from her disciplinary investigations considers other factors

why some employees abuse patients. She highlighted stress, being burnt out,

underpaid and poorly developed nurses as contributing factors. To minimise this

acting out behaviour, staff need to have a space to reflect on their relationships with

patients who are challenging.

7.3.6 Breakdown in staff supportive structures

Pertinent protective measures that can be utilised by the Trust to support staff from

making mistakes are clinical supervision, training and appraisals (Duffin, 2003). The

subject of clinical supervision and staff support came up in the findings. The lack of

good-quality and regular supervision was a continuous theme. This study found

clinicians do not always take up supervision and supervisors do not always pursue

this non-attendance. The supervisor coming from another discipline also presented

an issue. From the interviews, participants also reported supervision was used for

being reprimanded and the supervisor checking up if targets were being met.

Discussion around clinical work was avoided. Not all supervisees reacted

constructively when challenged about their clinical practice. Some supervisors, as

highlighted by Marcia and Pam, can be reluctant to challenge supervisees as they

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are not competent, confident and skilled to deal with the reactions from the

supervisee and afraid of a grievance being raised against them (Archibong and Darr,

2010). In disciplinary hearings, the lack of supervision is regularly raised as mitigating

circumstances.

With the low levels of staffing in the clinical area and the constant demand of meeting

patients’, carers’ and managers’ demands and expectations, clinicians in this study

found it difficult to attend clinical supervision and mandatory training. At the same

time, Trusts are being annually measured on the number of staff who have

completed the mandatory training. To address this issue, Trusts have developed

online training where staff can sit in front of a computer screen and undertake this

without having to leave their clinical area. Questions have been raised by participants

in the interviews about the effectiveness of this approach for some training. Training

in equality and diversity has been reduced from a one day to a one-hour online

activity. In this study BME participants in particular expressed anger and cannot

comprehend the value of this method to deliver training around such a complex and

challenging area as race, diversity and culture.

7.4 BME employees in the Trust

Examining the secondary data (Dixon-Woods, 2012), such as the Trust quarterly

magazine and various reports (as the RES) and the Service and Workforce Equality

Report), provided an opportunity to consider the representation of BME staff in the

Trust. On the surface, BME employees are included and represented in magazines

and brochures. Pictures of contentment and inclusion are conveyed in this literature.

Conducting this study within the Trust and using critical ethnography the findings

conveyed other realities.

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7.4.1 Recruitment of BME staff

To provide services to the population it serves, the Trust is reliant and dependent on

BME staff. This study found BME employees make up 38% of the workforce in the

Trust. Black African employees are the largest group (19%) within the BME labour

force. Within ancillary, nursing and HCAs/support staff BME employees comprise the

largest group. BME staff represents over 60% of registered nurses. Sixty-nine

percent of HCAs and support staff come from BME backgrounds. BME nurses and

HCAs/support staff are an integral resource and the Trust could not exist and provide

the care to the population it serves without this group. Healy and Oikelome (2006)

argued the NHS could not survive without overseas qualified professionals and BME

staff.

At times of staff shortages and government initiatives as the NHS Plan (DoH, 2000)

to increase the number of nurses in the Trust, BME nurses and HCAs have been

recruited. To meet the shortfall of nurses, the Trust in the recent past has appointed

newly qualified nurses without going through the conventional selection and

recruitment process. Repercussions from this initiative came up in the interviews.

Some managers believed incompetent nurses were employed and these nurses

have presented problems. No additional evidence was found in this study to

substantiate this claim. Recruitment details of BME nurses who went through the

disciplinary process were not provided.

The negative perception towards BME staff at the recruitment and selection stage

when candidates were interviewed for posts in the Trust came up in this study. When

asked about managing staff from different and diverse backgrounds, George

reported most candidates responded to this as a problem that needed to be

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managed. The constructive participation made by BME employees in the NHS were

not acknowledged by candidates seeking employment in the Trust. Simpson et al.

(2010) also reported a denial of the positive participation of BME healthcare staff in

shaping the NHS.

7.4.2 Socialisation and the working practices of BME staff

From this study there is no evidence of nurses appointed to the Trust with an

overseas nursing qualification. The pre-registration nurse training undertaken by

BME nurses was from UK higher educational institutions. There was recognition from

Denise that the Trust has been ill-prepared for black African nurses and HCAs born

outside the UK. Although these nurses have trained here, there is a perception that

the formative education has come from their country of origin. In this study Black

African nurses and HCAs not having a foundation in British education and not

socialised into the British way of life were cited as reasons why this group found it

difficult to integrate with other staff in the Trust. Within the main site of the Trust,

noticeable pockets of segregation were observed around racial lines. Some clinical

areas have predominantly white staff whereas other settings are staffed

predominantly by BME staff.

This study found the difference in the working practices and behaviours of BME,

particularly black African nurses and HCAs was attributed to their divergent

socialisation, education and cultural experiences. From the interviews Black African

nurses and HCAs were perceived as having a more paternalistic attitude in patient

care in comparison to their white counterparts. This approach contradicted the

‘recovery model’ promoted by the Trust.

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In terms of relating to authority figures this study found, black African staff were

observed bowing to Trust executives when they arrived in the clinical area. Initially

this behaviour was ridiculed but on further investigation bowing was understood to

convey respect. Johns (2005) reported BME nurses who cannot present themselves

in the ‘white way’ or mainstream way are negatively perceived by white colleagues.

For Hyacinth adapting to anglicised behaviour meant BME staff losing their identity.

In another interview Denise reports a BME HCA’s direct approach to a senior

manager for a pay increase was perceived as “shocking”. In their study, Archibong

and Darr (2010) found the different styles of communication and behaviour were

negatively interpreted by colleagues and senior managers.

Shauna found some nurses expressed their frustration to a manager about the

attitudes and performance of an overseas BME HCA who had recently come to the

UK and found employment in the Trust. In accordance with her working experiences

back home the HCA carried out her list of allocated tasks. Once she had completed

them, she felt her work was done. She was unaware of NHS working practices and

had not been advised or supported by her colleagues, who instead reported her to

the manager. Archibong and Darr (2010) stated that managers lacked confidence to

deal with issues informally. For this BME HCA, her colleagues treated this behaviour

formally instead of informally. In this study managers were not the only ones to opt

for the formal route.

Issues around the use of own position to reward oneself came up in this study. A

senior white manager reported a black African nurse felt it was her prerogative to

award herself the financially lucrative shifts as she considered this was the benefit of

working hard to gain a higher banding. Fearfull and Kamenou (2007) found cross-

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cultural communication and behaviour around working attitudes and authority was

misinterpreted. Alleyne (2004) highlighted that subtle and attacking comments were

made to undermine the culture and behaviour of BME staff.

This study found some white managers, who have been in the Trust for many years

and have worked closely with black African staff in particular, took time to find out

issues presented by BME staff. For example, these managers could not understand

why some BME employees in low positions exerted influence and control over senior

colleagues in the workplace. When these managers took the time to find out, issues

around status were unearthed among BME cultural groups. Details of BME

employees working in low positions in the Trust and occupying positions of chiefs,

nobility or pastors in their homeland came to light.

7.4.3 BME staff treated with suspicion and distrust

In this study there was a perception by some senior managers that BME, particularly

black African employees were only motivated by money and worked in certain

settings that paid extra allowances. As the areas were well staffed and resourced,

there was a held belief that black African nurses and HCAs worked in these settings

to preserve their energy so that they could work elsewhere after their shift. Larsen et

al. (2005) and Henry (2008) found nurses from overseas were perceived as only

working for their own economic gains.

With a new computer program installed in the Trust, managers reported that BME

nurses and HCAs were found to be working back-to-back shifts and working over and

beyond working time regulations in the NHS. Senior BME nurses, who have been

involved in the disciplinary investigation, reported that some BME nurses and HCAs

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who were found asleep on duty or making mistakes administering medication had

been working excessive hours.

Without evidence provided and figures published by the Trust, it is difficult to

determine the scale of the number of BME employees who are breaking the working

time directives. Although the new computer program was installed to facilitate

efficient use of resources, there was inference about this system also being used to

monitor the working hours of BME nurses and HCAs. Lewis (2011) found BME

nurses and HCAs were targeted by NHS anti-fraud investigators for fraud or criminal

offences related to false documents. In the RCN studies by Pike and Ball (2007) and

Dhaliwal and Mackay (2008), BME employees were closely monitored for their

conduct and performance. This could correspond to the ‘stop and search’ actions of

the UK police towards BME young males.

This study found BME staff who reported in sick were treated with suspicion. There

was a thought that they were working elsewhere. Black African staff visiting their

homelands and not returning at the end of their planned leave due to sickness were

perceived as pulling a “fast one” and lying. Despite producing medical documentation

the validity of the certificate was suspected. In another case around the authenticity

of official documentation the genuineness of qualifications, as Ann reported in her

case, was also questioned. Likupe (2006) found the authenticity of qualifications of

BME employees was doubted. Archibong and Darr (2010) reported BME employees

were perceived not to be committed to their jobs.

When some BME employees had been investigated by senior managers about

breaking working time regulations, extreme personal circumstances were disclosed.

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Motivation for working extra hours was not intentionally to break the law but due to

personal situations. When senior managers such as Lisa heard these accounts from

their BME employees under investigation, they used a softer tone and had an

empathic attitude. Negative judgements were withheld. In comparison to when

employees were perceived to be intentionally committing fraud, a harsher and

exasperating tone was observed in the interviews.

7.4.4 Impact on BME staff

Some participants in this study observed and reported the impact of these negative

perceptions on BME staff. Denise found morale among BME nurses to be low. These

staff absorbed and internalised the idea that they could not be good nurses. Others

saw themselves as second-rate nurses and placed no value on themselves of being

promoted in the Trust. Henry (2008) reported that BME staff become disillusioned

about their career prospects in the NHS. BME employees perceived as not being

good enough was found by NHS Northwest (2008). Dhaliwal and McKay (2008)

reported there was a perception by white managers that BME nurses were not

capable of achieving managerial and senior positions.

Parallels to oppression are drawn between the plight and experience of BME people

in society to the experience of BME staff in the Trust. Britain’s historical colonial past

and how this permeates to the present day was raised by Ann who felt the position of

BME staff in the NHS was already determined before they arrived. She was

pessimistic that no matter how hard BME people worked, they would never be given

the same status and recognition as their white counterparts. She called this the

“black tax”. To support this perception, several participants in this study gave

examples of the over-representation of BME employees at the lower bandings

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(Likupe, 2006; Archibong and Darr, 2010) and the under-representation at senior

positions. The descriptive statistics on the Trust workforce show the number of BME

nurses decline as they progress through to higher positions and BME HCAs occupy

higher numbers in lower bandings.

What went on beyond the walls of the Trust was conveyed within the Trust. Leona

talked about how BME people were socially constructed. She described BME people

particularly of black descent as oppressed, treated with suspicion, disproportionally

stopped and searched by the police and perceived as unintelligent.

7.4.5 The ‘Black African’

In reality, there is no such thing as a ‘black African’. The continent of Africa is vast

and made up of many countries. Each country within the vast continent is diverse

and different in their culture and traditions. In this study the black African has been

constructed, perceived, simplified and homogenised as one body. The issue around

black Africans not being able to integrate into the Trust (as discussed above) was

presented as the problem. This study found BME employees were always compared

to their white counterparts. White employees were never compared to their BME

counterparts. Allen (2006) stated ‘white’ was depoliticised and perceived as the norm

of power, knowledge, civilisation and goodness. Madison (2004) emphasised how

people were presented held power and meaning.

In the present study BME nurses and HCAs were distinguished from each other. For

example, Black Africans nurses and HCAs were distinguished and categorised as

‘good or bad’. Zimbabwean nurses were perceived to be responsible and able to fit

into mainstream working practices. Male Nigerian nurses and HCAs were perceived

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as having problems to adapt to the mainstream culture in the Trust in this study.

Reference to West African nurses having a “gambling and a bit of a drink problem”

was reported by senior managers interviewed in this study. Black African nurses

dismissed from the Trust in this study were compared to black African nurses struck

off the NMC register. Carter’s (2000) study perceived BME staff as troublemakers. In

this study, nurses and HCAs from West Africa (particularly Nigeria) were considered

troublesome by senior nurses. Cooke’s (2006b) concept of ‘bad apples’ could also be

applied to this group. Unlike Henry (2008) where managers preferred African

Caribbeans to black Africans, this study found African Caribbeans absent in the

discussion. An attempt to break away from the homogeneity of BME employees

started to appear in my findings, particularly among black African employees.

Johns (2005) implied BME employees who did not present themselves in the white

European ways were negatively perceived. Fitting in with the main established ways,

namely white European was favoured over BME employees’ skills and experience.

7.4.6 Discrimination and racism within and between employees

The study revealed perceptions of racism and discrimination across the Trust. Some

managers showed their animosity towards BME employees by letting them make

mistakes and then intervening by initiating disciplinary actions for these mistakes.

Some interviewees expressed disbelief around the perception that some managers

held about BME employees’ main motivation being a financial one. These

interviewees such as Gerard could not understand why this held perception was not

being challenged and treated as racism by the Trust. Racism and discrimination, as

observed by Ali were not only polarised between ‘white and black’ staff but also

highlighted between BME individuals and groups.

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A shift to move away from ‘blacks versus whites’ and the rivalries within and between

the different and diverse BME groups in the Trust is highlighted in this study. Racism

between Mauritian, Ghanaian and Nigerian staff was reported in my findings. As

found by Likupe and Archibong (2013), racism between BME employees surfaced in

clinical areas employing diverse racial and ethnic groups.

Relationships between BME managers and BME staff were unearthed. From this

study some BME managers could distinguish between cultural working practices and

the poor performance and conduct of BME staff. Despite being threatened with

grievances and accusations of racism and bullying, these managers were not afraid

to challenge the improper working practices and would also present evidence against

BME staff at disciplinary hearings.

In the current study, playing the ‘race card’ was not only undertaken by BME staff but

also advocated by some white managers in the Trust. These managers advised BME

employees to use this approach particularly to get on courses and training that were

popular and oversubscribed. Some poor performing BME staff when challenged

about their practices used the ‘race card’ as a defence.

7.5 Disciplinaries in the Trust

Disciplinary action is legitimate to manage employees who breach their contract of

employment and continually fail to meet the required standard of behaviour, conduct

and performance set out by the Trust and professional regulatory bodies. Disciplining

staff should be used as the last option.

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7.5.1 Descriptive statistical data on disciplinaries

Under the Equality Act 2010, there is a legal requirement on NHS Trusts to publish

details of their workforce that includes disciplinaries to the public. Although this legal

compliance was met by the Trust in my study, information available on disciplinaries

was minimal. The data on disciplinaries from the Trust was limited as age, gender,

area of work, occupational and professional groups were not recorded. The lack of

these data made it difficult to determine if certain employees in the Trust were more

susceptible than others to disciplinary action and if: a high turnover of staff; issues

around recruitment, retention and high levels of sickness; a disaggregation and

reconfiguration of services were contributory factors to disciplinaries.

From the descriptive statistics in chapter 4, the total number of the workforce for

2011 to 2012 was 2330; 54% (1305) were white and 38% (918) were from BME

background. The total number of staff involved in disciplinaries was 2.4% (56). Eighty

percent (45) of staff came from BME backgrounds. Looking at the data on

disciplinaries, from 2008 to 2012, there were always more BME employees put

through the disciplinary process in comparison to white staff. From 2008 to 2009, out

of 37 employees disciplined 25 were BME staff. Between 2009 and 2010 there was

27 BME staff in comparison to 11 white staff disciplined. From 2010 to 2011, 18 BME

employees were disciplined in comparison to 11 white staff.

These data clearly demonstrated that BME employees in the Trust were over-

represented in the disciplinary process. The findings from this study supported the

work of Beishon, et al. (1995), Carter (2000) and Archibong and Darr (2010). Thus,

this adds to a growing body of research showing a clear over-representation of BME

employees in the disciplinary process in the NHS. Archibong and Darr (2010) also

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concluded that BME employees were disproportionately disciplined in the mental

health field.

Looking at the data on disciplinaries, from 2008 to 2012, it was noticeable that the

number of white employees did not exceed BME employees in any of the categories

listed. BME employees always received more first, final written warnings and

summary dismissals than white staff.

When suspensions were recorded for the first time in 2011 to 2012, BME employees

were suspended almost three times more often than their white counterparts (21:8). It

was not clear why there was a significant increase in the numbers going through the

disciplinary process from 26 to 56 (2010–2011 to 2011–2012).

Despite taking measures to reduce economic costs, senior managers, in the current

study, reported that the Trust Board had not considered the cost of disciplinaries,

particularly suspensions, on the Trust. The NAO (2003), Murray (2005) and Stone et

al. (2011) have conducted research to calculate the economic and emotional costs of

suspension.

Murray (2005) and Stone et al. (2011) looked at the emotional impact of suspensions

on the employee under investigation but they did not look at the effect suspension

had on the clinical team. My study was able to look at the impact on the clinical team.

After the hearing, the suspended employee usually returned to work quickly (as

described in chapter 5). The team was only informed of this at very short notice and a

lack of consideration was given to preparing all parties for this return. Tensions and

anxiety prevailed particularly if colleagues from the team had to give evidence

against the person under investigation. Team dynamics were affected, relationships

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became strained and employees started distrusting each other. These issues were

not worked through. Cases of grievances being taken out have been reported

anecdotally in my study.

7.5.2 The wider context: outside the NHS

Outside the NHS a similar picture seems to emerge about the experience of BME

staff and disciplinaries. A disproportional representation of BME employees involved

in the disciplinary process is found in other public institutions and the private sector.

Archibong and Darr (2010) found BME employees in the police service and local

government reported similar experiences to BME employees in the NHS. The

Equality Challenge Unit (2009) found a disproportionate level of scrutiny on BME

staff in higher education. John (2014) revealed BME solicitors were subjected to

severe sanctions in comparison to their white counterparts.

International studies in nursing looking at the phenomenon in English speaking

westernised countries are sparse and needs further investigation. However, from the

USA, the National Council of State Boards of Nursing (2009) found a higher

percentage of African-American, Native American and Hispanic nurses were

disciplined in comparison to the general nurse population. Other international studies

on disciplinaries involving nurses (Hudspeth, 2009 and Pugh, 2009) did not consider

race and ethnicity.

7.5.3 Capability procedures

Archibong and Darr (2010) found managers were erroneously using disciplinary

policies to deal with capability issues. Similar issues were found in the Trust in my

study. Capability policies in this Trust recently revived by an interim chief executive

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were under-utilised and not seen as user-friendly. In addition Hazel, Ali and Gerard

separately reported managers were not following the suspension policy and not using

suspensions as a last resort. From the interviews with senior managers it was

reported that disciplinaries have reduced since the capability policy was reintroduced

and suspensions have also declined since they have been monitored by the Trust

Board. No further evidence has been provided to corroborate this claim. However,

measures supported by the Trust Board, in this study, were more likely to succeed if

they had financial implications. This was in contrast to the lack of support given by

senior Trust executives to the E&D agenda (Carter, 2000; Healy and Oikelome,

2006).

7.5.4 Reactions to the phenomenon investigated

The subject of the disproportional representation of BME employees in the

disciplinary process is sensitive (McGarry, 2010) and political. From the data

presented in this study, the Trust Board executive’s perceptions (see section 3.3.1)

about the ‘apparent’ over-representation of BME employees disciplined could be

dispelled. However, despite the data presented by some BME and white participants,

particularly managers, it is strongly felt that there was no disproportional

representation of BME employees in the disciplinary process. The other assumption

of BME employees on lower bands 1 to 4 were more likely to be disciplined was

unfounded. More employees from bands 5 to 8 were disciplined.

Participant observation used in ethnography was a useful instrument to investigate

how employees reacted to this over-representation of BME employees in

disciplinaries (Holloway and Todres, 2010). In this study discomfort, hostility and

resistance were observed in the non-verbal behaviours amongst some employees,

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particularly senior managers. Contemplating the phenomenon was difficult

particularly for senior managers. The size of the issue (2.4%) was derided and

quickly dismissed. Arguments put forward by the participants to stop the discussions

about disciplinaries was that the Trust had to deal with more ‘important’ issues

around its future and focus on poor-quality care. Issues of poor conduct and

performance found in disciplinaries were divorced from the struggle the Trust was

having in some clinical areas in providing good-quality care. The issue of

disciplinaries in this study tended to be compartmentalised and not considered in the

wider context.

In this study, defensive behaviour of separating and denying the phenomenon

seemed to be a strategy to deal with this fear, discomfort and anxiety. To avoid

looking at anxieties that surround contentious subjects, Alleyne (2005) using

psychodynamic concepts stated defence mechanisms were used. One common

mechanism that is used by individuals to evade complex threatening emotions and

reality is denial. Like individuals, Obholzer and Roberts (2002) stated institutions also

develop defences against painful emotions. Another mechanism adopted by

individuals, in this study, is rationalisation. Here, rational reasons are given to make

light of difficult issues (Gabriel, 2004).

Over the past few years, the Trust in this study has reported the high numbers of

BME employees in the disciplinary process. This has been forced by the legal

requirement on the Trust to publish details of their workforce. Up until this study, little

visible attempt has been made to understand why this issue exists in the Trust. This

has frustrated BME staff in particular who felt aggrieved that the Trust was not

actively interested in the welfare of its BME staff. Participants in the interviews

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reported angry outbursts at BME conferences when disciplinaries have been

mentioned. White senior managers and the Trust Board were also reported to be

absent from the conference. There is a perception from BME participants in the

interviews that these managers did not attend because they were afraid of the

backlash from BME employees. Senior white managers from the Trust have

expressed their discomfort in attending the BME Staff Group and conferences as

they were not made to feel welcomed and were attacked and accused of racism

when issues around inequalities experienced by BME employees surfaced. Owing to

the highly expressed emotions, this study found that an open and authentic dialogue

around disciplinaries involving BME staff is difficult to sustain in the Trust.

7.5.5 Equality and diversity

Apart from meeting the statutory requirements, it was unclear how the data on

disciplinaries was used by the Trust in this study to inform their policies and

practices. Despite there being the Race Equality Steering Group, Workforce Equality

Group, Equality and Diversity Group and the BME Staff Group, it was unclear how

data on disciplinaries informed a coherent strategy and the various initiatives. The

inconsistent use and poor-quality data on disciplinaries provided by NHS Trusts were

highlighted by Archibong and Darr (2010) and Stone et al. (2011).

Many participants in this study claimed Trust executives were not taking the E&D

agenda seriously. Healy and Oikelome (2006) conveyed E&D initiatives make little

difference. Carter (2000) found the E&D agenda was a paper commitment that was

poorly embraced by Trusts and relegated at a time of economic crisis. Senior

managers in this study cited the Trust’s preoccupation with financial issues relating to

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its uncertain future as a reason for the E&D agenda not being a priority. BME staff

felt their experiences are neglected and marginalised.

There are several groups set up in the Trust that incorporate the E&D agenda.

Notable groups are the Race Equality Steering Group, Workforce Equality Group,

Equality and Diversity Group and the BME Staff Group. The purpose and the task of

each group and how these groups interrelate were unclear. Similar agendas

appeared in each group. From the meetings observed the attendance of white staff

and clinicians were scarce. Questions were raised about the application and

integration of the E&D agenda into the Trust’s daily practices and the impact on the

working experience of BME staff. Healy and Oikelome (2006) found E&D initiatives

focused on changing individuals rather than changing and challenging NHS culture.

In this Trust’s policies related to disciplinaries and capability procedures, an initial

statement on equality was published, affirming that all staff should be treated equally

and fairly. Monica who is closely involved in the disciplinary process highlighted: “our

disciplinary panels don’t necessarily consist of managers who have had any E&D

training.” Paul revealed that he did not consider the ethnicity of an employee under

investigation as an issue. He admitted his lack of training as chair of the disciplinary

panel. He was more cautious in making the ultimate decision of whether or not to

discipline. If some managers do not have any E&D training and do not consider the

ethnicity of a BME employee how can BME employees be treated fairly and equally?

7.5.6 Disciplinary investigations and hearings

In this study, the quality and rigour around the investigation depended on several

factors. Carter (2000) found the disciplinary process was weighted against BME

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employees. Cooke (2006a) found managers were initiating disciplinary action on ‘gut

feeling’ rather than collecting the facts to make an informed decision. Unlike my

study, Cooke did not consider the role of other employees directly involved in

investigations.

To maintain impartiality, facts rather than the IOs’ opinions need to be presented at

the disciplinary hearing. In this study, it is reported by some panel members that

some IOs presented opinions and unrelated material rather than facts from their

investigation at the hearing. Not all IOs were given training to undertake their role. In

the Trust there was no standardised training to deal specifically with investigating

disciplinary cases. From the interviews, this study found some IOs were determined

to secure a ‘conviction’ at all costs and reacted strongly when the chair has decided

not to discipline an employee. The neutrality and objectivity of the investigation is not

always adhered to.

In the Trust, all IOs have an HR advisor throughout the duration of the case to advise

and ensure that the disciplinary process is followed. In some instances, this study

found from interviews the HR advisor/manager has tried to influence what information

should be included or excluded in the investigation findings. IOs have perceived HR

advisors as erring on the side of management. Some HR advisors reported they

have to intervene when the IOs abdicated responsibility and/or were not confident in

the process. IOs have not always agreed with the outcome made by the chair and

found inconsistencies in outcomes for similar cases. Monica, in her interview

highlighted the disparity in outcomes between white and BME staff.

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With no administrative support, the writing up of the findings from interviews fell on

the IOs. There have been instances when all the clinical staff related to the employee

under investigation needed to be interviewed. The burden of writing up investigations

has delayed cases from being heard while suspended employees continued to stay

at home. IOs in the interviews also complained that the burden of administrative

tasks associated to disciplinaries prevented them from undertaking preparatory work

to prevent disciplinaries.

Attention has been drawn to the chair of the disciplinary hearing in this study. As

reported by Monica not all managers undertaking this role have had training in

disciplinaries. Also some chairpersons have not undertaken training in E&D.

Archibong and Darr (2010) also found managers were not provided with necessary

training and skills to deal with issues around diversity and difference linked to race

and ethnicity. Managers, such as Pam, who chaired disciplinary hearings have

emphasised that their professional training and experiences did not prepare them for

the complexity of some cases.

This study found the Trust disciplinary panel composition consisted of men and

women from diverse ethnic backgrounds. Some panel members have reported in

their interviews that they have been specifically selected because they were from a

BME background. This has raised suspicion because the cases recalled have

involved ‘problematic’ BME employees who have been dismissed. BME panel

members felt they have been selected to anticipate any accusation of racial

discrimination if the case was referred to an Employment Tribunal.

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The findings from this study reveal BME panel members were also selected as there

was an assumption that they would understand all BME cultures and they could

distinguish between cultural and competency issues. BME panel members reported

this was an unrealistic expectation and expressed some concern that BME

employees were homogenised.

There was a perception from staff representatives and panel members that the

professional leads sitting on the panel recommended harsher sanctions for members

of their own profession. Gerard reports the sanctions advocated were

disproportionate to the offence. As discussed in section 7.5.1 BME employees

received more summary dismissals, final and written warnings than their white

counterparts.

Cooke (2006a) looked at the role of TU officials in her study. She did not consider the

relationship between the TU official and employee under investigation. This current

study has considered this area. Employees, such as Lyn, under investigations

perceived a conflict of interest between employees who worked full time in the Trust

and undertook the additional role of TU officials. There was a perception that these

TU officials worked closely to managers in their day-to-day work and managers could

influence them so that could impact on the representation. Also there was a lack of

trust around TU officials breaking confidentiality and sharing information with

managers outside the disciplinary process. Archibong and Darr (2010) found TU

representatives were not always aware of and sensitive to the cultural needs of the

BME staff they were representing. This is not found in this study.

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In this study BME staff perceived HR managers as being discriminatory and not

looking after the well-being of employees. There was a strong perception that the HR

department was part of management and treated BME employees more harshly and

insensitively. Archibong and Darr (2010) also found BME employees were treated

harshly by HR managers. There was a perception from HR managers interviewed

that the HR department was an easy target and a scapegoat for the organisation,

particularly at a time of chaotic change and uncertainty around the Trust’s future.

Cooke (2007) argued Trust executives, who introduced poorly planned changes,

were not held to account as attention was diverted to employees on the front line who

were punished for the mistakes of others.

7.5.7 Disciplinary outcomes

From the qualitative findings in this study, there was a perception that BME

employees were treated more harshly and insensitively than their white colleagues.

Some managers had a low threshold and wanted to take a formalised approach.

Others had a ‘personal vendetta’ and used the discipline process. In other cases,

there was a perception that employees were used to make an example to warn other

employees. Managers in some cases did not always consult HR when considering

the disciplinary route. HR managers themselves did not always follow the disciplinary

policies. Cooke (2006b) found similar findings and stated managers used quasi-

formal disciplinary action against employees who could not be disciplined formally.

Her findings did not report if this included BME employees.

In this study, employees under investigation were treated more fairly if they could:

comprehend the seriousness of the allegation; accept responsibility for their conduct

and performance; reflect and demonstrate insight to the concerns and articulate on

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the allegation. How BME employees, under investigation, presented themselves in

their hearing in the Trust was reported. They were perceived as inarticulate in

presenting themselves, not showing remorse or accepting responsibility and lacking

insight.

This study found some white chairpersons were more cautious about making

decisions about BME employees under investigation. Also sanctions around similar

cases were inconsistent and BME employees were perceived to be treated much

harsher than their white counterparts. Some IOs and professional leads perceived

individuals from BME groups who were under investigation were scapegoated

(Cooke, 2007). In this study, there was a strong reaction towards managers and

supervisors who had not provided regular support and turned a ‘blind eye’. They

were perceived to be “let off the hook” and not held to account.

7.6 Summary

The findings from the data collected have been discussed in relation to existing

literature in this area. Exploring the over-representation of BME staff involved in the

disciplinary process in an NHS Trust could not be reduced to single factors and

considered in isolation. This study shows the experiences and perceptions of BME

staff, and the personnel involved in the disciplinary process need to be considered in

the constantly changing context of the Trust.

Through focus and critical ethnography this study is able to offer additional

perspectives on the disciplinary process involving BME staff and build on the work of

Beishon et al. (1995), Carter (2000), Cooke (2006a, 2006b and 2007) and Archibong

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and Darr (2010).The unique findings from this study and how they advance research

in this field will be discussed in the final chapter.

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Chapter 8: Conclusion

8.1 Introduction

This concluding chapter summarises the contributions this study has made to

understanding the over-representation of BME employees involved in the disciplinary

process in one NHS Trust and how this relates to the wider context.

Recommendations to minimise disciplinaries will be proposed to the Trust. The

strengths and limitations of the study are discussed. Finally, dissemination of this

study’s findings are considered

8.2 How does this study advance research in the field?

From the literature search and review, no studies can be found where ethnography

has been used as a methodology to explore representation of people from BME

groups in mental health disciplinaries, an area that is ‘taboo’ and under-researched.

Confidential research into the disciplinary process was investigated directly from the

inside of an NHS Trust. The use of ethnography is able to uncover new ground and

identify key factors as to why over-representation of BME groups, in comparison to

white ethnic groups, existed in this Trust. Through fieldwork, participant observation,

journal/diary, secondary data and semi-structured interviews, I was able to examine

the culture of a single Trust and investigate the disproportional representation of

BME staff involved in the disciplinary process in the workplace. As part of the study, I

was able to obtain permission to observe a disciplinary hearing and interview staff

with various roles and responsibilities in this and other disciplinary proceedings.

Multiple realities to understand why there is a disproportional representation of BME

staff in the disciplinary process were obtained from employees directly involved in the

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disciplinary process. These employees came from diverse backgrounds and

occupied different positions, bandings, roles and responsibilities in the Trust.

This research is unique and various perceptions are obtained about the disciplinary

process from the staff directly involved. The study highlights that the disciplinary

investigations are not always impartial and based on ‘facts’. Judgements are

presented in the investigation report compiled by the IO with the support of the HR

representative. IOs carrying out this role are not always trained to undertake the

investigation. The relationship between the IO and the HR representative is

examined. Rather than presenting all the facts, some IOs reported that some HR

representatives tried to influence what to include or exclude in the report. This means

that the findings are presented in a way that favours management. Some HR

representatives emphasised that they are forced to step in to take an active role,

particularly when IOs abdicate responsibility and are not confident in carrying out the

task. Some panel members highlighted the report presented by the IO to the

disciplinary panel has included findings that are not directly related to the employee

conduct and/or performance under investigation. Some HR representatives reported

some IOs are determined to secure a ‘victory’ at all cost and take umbrage when

their case is dismissed by the panel.

There was a perception that some professional leads sitting on the disciplinary panel

recommend the severest sanctions to staff coming from their own discipline. A lack of

tolerance was observed among some panel members, particularly the chair, when

BME staff under investigation were presenting and defending their own cases. In

some cases, the chair of the panel would have more information about the employee

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under investigation than the other panel members. It was unclear if this had any

bearing on the outcome.

BME staff were selected, on the panel, to offer a race and cultural perspective when

BME staff were investigated. There is an assumption and unrealistic expectation that

these BME panel members were familiar with all BME cultures. Some BME

employees are specifically selected to sit on the panel, particularly when a BME

employee is investigated and likely to be dismissed. This is to anticipate accusations

of racism should the case be referred to an Employment Tribunal.

It was reported that some white chairpersons of the disciplinary panel were too

cautious in making decisions involving BME staff. Varying standards of sanctions are

imposed for similar cases. Some employees have been dismissed when others have

been issued a first warning for offences that are perceived as similar. BME

employees under investigation are perceived to be inarticulate in comparison to their

white counterparts. White staff were perceived to demonstrate insight, accept

responsibility and show remorse for their wrongdoings in comparison to their BME

counterparts.

Using an ethnographic methodological approach, this study provided another

perspective to understand the personnel, structures, systems, processes and

relationships involved in a complex, challenging and sensitive phenomenon in its

natural setting.

8.2.1 Implications of this study for policy and clinical practice

Despite disciplinaries being experienced by 56 employees or 2.4% of the Trust

workforce in 2011 to 2012, 45 (80%) were from BME groups. This matter should not

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be trivialised. The issues explaining the over-representation of BME staff in

disciplinaries needs to be considered in the wider context and cannot be reduced to

single factors. With limited finances, greater pressures are placed on the NHS to

meet the growing public demands and expectations. People today are living longer

and, as a result, health-related issues are arising from this. As a consequence, the

Trust, as part of the NHS, is going through massive change to deliver more services

with fewer resources. This transformation programme is having a huge impact on

employees who provide these services. Today BME employees make up 38% of the

workforce in the Trust. If all these staff left, the Trust would cease to function in its

present state. It is vital the Trust takes into account the under-representation of BME

figures occupying senior positions; an over-representation of BME applicants who

are not recruited; an over-representation of BME staff in the disciplinary process and

the effect that this can have on BME staff morale.

The issues around disproportional representation of BME employees involved in the

disciplinary process are not only a Trust, but also a wider societal issue. Archibong

and Darr (2010) reported the disproportional representation of BME police officers in

the disciplinary process. Further investigation about this phenomenon also needs to

be undertaken in English-speaking westernised countries as limited international

studies (Pugh, 2009; Hudspeth, 2007 and 2009) were found in the literature search.

These studies did not recognise that ethnicity had any bearing on disciplinary action.

There are various legislations (Equality Act, 2010) and E&D initiatives in place. At a

time of austerity, the E&D agenda has been marginalised by the coalition-led

government. As a consequence of the coalition government making pledges to cut

down on red tape and bureaucracy, ethnic monitoring and reporting needs to

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continue to determine whether issues facing BME staff are changing for better or

worse. This task must not be perceived as a tick-box exercise with only minimal

information obtained. Meaning needs to be gained from the analysis of the data

collected and this information should be shared. The E&D agenda needs to be

owned from the top and threaded across the NHS to instil confidence in BME

employees that E&D issues are taken seriously and not negatively portrayed in the

NHS and BME Staff Survey.

The economic pressures faced by the Trust in this study and the impact of releasing

staff to undertake training when staffing levels are greatly affected cannot be ignored.

This creates various dilemmas such as the training provided by the Trust. To solve

this issue, the Trust has introduced online training. This raises questions of whether

complex areas such as race, culture and diversity can be reduced to an online

computer activity. Particular attention needs to be given to the training of IOs and

panel members when investigating and hearing cases that involve race, diversity and

culture. In addition, the training of employees undertaking the role of IO and chair of

the panel also should be reviewed. This is to demonstrate that cases are decided on

facts and not supposition.

At a time of continuous disaggregation and reconfiguration of the Trust, consideration

needs to be given to how staff are recruited, inducted and supported to engage with

challenging and complex service users. Focus on redesigning services should not

solely be on curbing costs. The ethnic and skills mix of teams needs to be monitored

to ensure services do not get segregated around racial and ethnic lines. When

employees are redeployed to other services in the Trust, consideration should be

given to how the employee and team are prepared to receive each other.

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This study reinforces that regular good-quality clinical supervision undertaken in a

safe environment is needed for clinicians to reflect on blind spots, particularly with

service users who present challenges. The working environment and structures need

to support supervisors and supervisees to undertake supervision. Supervisors and

line managers need to be trained and supported by their managers to engage with

teams and employees who present persistent challenges. This study did find

secondary data of nurses and HCAs committing gross misconduct towards patients.

Whatever reasons may lie for poor conduct and performance, nurses need to be

challenged, held accountable and take responsibility for their actions. The clinical

area should not be a forum for nurses to work through their own unresolved issues

and misfortunes, particularly when vulnerable patients are present and need to be

treated. If supervisors and managers are afraid to highlight the conduct and

performance of teams and employees and the employees behave in a defensive

manner, this cannot be ignored or left to one individual to manage. Ultimately the

safety and well-being of patients and their carers need to take precedence over

everything that is undertaken by the Trust. Where appropriate, capability procedures

need to be reinforced with underperforming staff. Disciplinary measures should only

be applied when all other avenues have been exhausted.

Open and authentic dialogue about race, culture and diversity across the

organisation needs to be undertaken. This can only happen if employees feel the

environment is safe to share sensitive and emotionally charged information. The

issue needs to move away from the polarised split between ‘black and white’. This is

a complex issue and attention, as this study highlights, needs to be drawn to the

tensions between and within BME groups. Staff support groups, reflecting on team

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dynamics and relationships in the context of the clinical work, need to be

incorporated. This is important when relationships in the team are strained, morale is

low and employees are ‘acting out’. Without breaking confidentiality, further thought

needs to be given when employees who have been suspended are reintegrated into

the team. This is to prevent grievances from being raised.

Post-reviews of disciplinaries need to be undertaken to consider lessons that can be

learnt. Reviews need to include processes, systems, structures and outcomes.

Without breaking confidentiality, findings from these reviews could be put into themes

so a meaningful discussion can take place. The dialogue must not centre solely on

the quantitative data but also consider the experiences of all the staff involved. The

focus needs to be on changing the culture of the Trust as well as the employee so

that patient care is never compromised.

The Trust has demonstrated that it is prepared to allow research into a sensitive area

on its site. Further research in this area needs to be considered.

8.3 Study limitations

This study came from one NHS Trust and it is difficult to determine if the findings can

be generalised to other NHS Trusts. The literature search found a dearth of studies

on the disproportional representation of BME employees involved in the disciplinary

process in the NHS. A wider search and review of literature in other public bodies

needs to be considered.

All the data collected for this study came from the main site. It is difficult to know if

the findings from the main site could be applied to other sites within the Trust.

Gaining access to the gatekeepers was challenging as negotiations took a period of

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time where trust had to be gained. The research under the taught doctorate had to be

completed within a specified time. The pressure of time has had an impact on the

study. Gaining access to undertake a sensitive subject cannot be hurried. How to

access these areas needs to be considered at the planning stage.

Despite permission being granted to undertake the study, accessing forums where

discussions around disciplinaries took place was restricted. For example, each

disciplinary hearing has a pre- and post-panel meeting. Here, panel members meet

outside the disciplinary hearing. Access to meetings where HR managers discuss

workforce issues including disciplinaries at the senior level were denied. Some

meetings could only be attended once as there were long intervals between them.

The time of the next meetings fell outside the period given to collect the data.

Attending a meeting once had its limitations as it made it difficult to capture the

culture. This study presents a fragmented and incomplete representation of the

phenomenon.

For an ethnographic study, the findings came predominantly from interviews.

Interviews could be triangulated. Making comparison of what employees said to what

they actually did could not be observed. There were not many forums to attend and

observe discussions around disciplinaries. Discussions around disciplinaries

happened behind closed doors. Holding focus groups to gain an insight to how

employees react to the disproportional representation of BME staff needs to be

considered. The findings from these groups could be used to triangulate the findings

from interviews and participant observations from other settings.

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BME employees who had been disciplined did not participate in this study. Initially

four employees who had been disciplined did tentatively express interest in

participating through email. When arrangements were made to hold informal face-to-

face meetings with each employee at a time and a place of their choice and

convenience to discuss preliminary issues such as consent, they withdrew. TU

representatives, who were acting as the intermediaries, let it be known these

employees had declined as they would not want to relive their recent experience of

being disciplined and wanted to put this ‘raw’ ordeal behind them and move on with

their lives.

Having TU officials act as intermediaries presented another issue as this did not

consider staff who had been disciplined and not had TU representation. This group of

employees were inaccessible as not all employees belong to TUs and some might

represent themselves or have non-TU representatives accompanying them.

Another factor why disciplined employees did not come forward was considered. The

researcher being allocated a base within the HR department during the time spent in

the field could have been perceived with scepticism, particularly among BME staff.

The HR department plays a pivotal role in managing and conducting the disciplinary

process. Findings from the BME Staff Survey and interviews overwhelmingly

highlighted a lack of trust and suspicion towards the HR department. HR personnel

from this study were negatively perceived. The researcher being situated in the HR

department could arouse many fantasies about his neutrality and raise suspicion.

This episode raises issues of ‘positionality’ (Borbasi et al., 2005) of the researcher

that was overlooked when designing the methodology for this study.

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Owing to constraints and the time spent in the field, it was difficult to observe the

criteria required for ethnographic interviewing (Heyl, 2001). Although participants

voluntarily came forward to be interviewed, considerable time could not be spent

building up rapport and undertaking further interviews with the same person.

Participants were only interviewed once. There were no follow-up meetings for the

participants to go through their transcription and for the researcher to seek further

clarification and ask additional questions.

In the end, the findings from this study were constrained to disciplinaries taken

against nurses and HCAs. Access to disciplinary proceedings involving doctors and

other professional groups (outside nursing) could not be obtained. No doctors and

AHPs, such as psychologists, occupational therapists and psychotherapists, came

forward to participate. The perceptions of these groups of staff to the phenomenon

investigated is absent from this study.

Despite the study being restricted to disciplinaries involving nurses and HCAs, an

array of employees from diverse ethnic backgrounds, various bandings and different

roles and responsibilities in the Trust participated in this study. From participant

observations, 27 employees occupying different roles and responsibilities in the

disciplinary process provided their perceptions in interviews.

8.4 Dissemination of the findings

Themes of the findings of this study will be presented to the senior HR manager. This

will be followed by group presentations of the study to employees involved in the

disciplinary process in the Trust. Summaries and abstracts of the study will be sent to

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academic journals and conferences. Findings will also be adapted and incorporated

into teaching sessions involving healthcare professionals.

8.5 Summary

The findings of this study and how ethnography has contributed to explanations of

the disproportional representation of BME staff involved in the disciplinary process

are summarised. The study will be presented to the Trust together with

recommendations to consider how practices could be improved. The strengths and

limitations of the study are also considered.

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Appendices

253

Appendix 1: The disciplinary procedures examined in this study

This section provides a summary of the relevant stages, the process and personnel

involved in the disciplinary procedures examined in this study.

Informal disciplinary processes

All cases need to be investigated before disciplinary action is taken. The employee is

given an account of the concerns from the onset. Unless the allegations are serious,

informal attempts are made by the line manager to resolve concerns around the

standard of conduct, performance and behaviours of the employee. The line

manager will consult HR representatives. Depending on the employee’s needs,

clinical supervision, extra support as regular meetings and further training may be

introduced with action plans and review dates. This is to ensure all efforts have been

taken by the Trust and the employee to resolve the concerns. Confidentiality must be

maintained by all parties involved.

Formal disciplinary process

Formal disciplinary action is undertaken if there are no improvements in conduct or

there is a serious gross misconduct.

Investigation

An IO with delegated authority is allocated to investigate the employee who has

contravened Trust policy around code of conduct. The IO is supported by an HR

representative who may be a manager. In addition to the employee under

investigation, various staff related to the allegation may be interviewed by the IO and

HR advisor. After the investigation has been completed, the IO will produce the

management statement of the case with evidence to support. The designated officer

254

will decide if the matter will proceed to a formal hearing. If there is no case to answer,

the employee will be informed in writing.

Outcome of investigation

If a formal hearing needs to take place, the employee under investigation will be

given written details of the alleged misconduct and asked to attend the hearing.

Written details of the purpose of the hearing under the Trust’s disciplinary policy will

also be provided to the employee.

Employee representation

Throughout the disciplinary process, the employee under investigation has the right

to be represented by a work colleague or TU representative.

Suspension of staff

For serious allegations, the employee under investigation may be suspended.

Suspension is not a disciplinary action.

The disciplinary hearing and panel

The hearing has a chairperson who is supported by an HR manager and professional

lead. The chair of the panel is a designated manager who has the authority to

dismiss and suspend. The professional lead, where possible, is a senior professional

who comes from the same discipline as the employee under investigation. This lead

will offer advice on professional issues and standards. The HR representative will

assist and advise the chair of the panel. These three employees make up the

disciplinary panel that will hear the case, ask questions, seek clarification and decide

on the outcome of the case. The panel may adjourn the case if more information is

needed and then reconvene at a later date.

255

The employee under investigation is invited to attend the hearing with an employee

representative. The IO will present the case (for the Trust) with evidence against the

employee under investigation. The employee and representative are allowed to

respond to the case presented by the IO and provide explanations and mitigating

factors. Both management and the employee under investigation have the

opportunity to call and question witnesses. After the case has been heard, the panel

will take a break to decide on the outcome.

Outcome of hearing

The outcome can be no formal action or formal action to be taken. The chair of the

panel will convey the decision of the panel to the employee. If disciplinary action is to

be taken, the chair will state and give reasons for the sanction imposed. The

employee has an opportunity to lodge an appeal against the outcome. An appeals

panel will hear the case.

Appendix 2: Recruitment letters

256

RECRUITMENT LETTER – Observations

Version 2 – 31/10/2012

Date

Dear

The Apparent Over-representation of Black and Minority Ethnic (BME) Employees in

Disciplinary Hearings in an NHS Trust

There is recognition in the Trust of the over-representation of BME staff in disciplinary

hearings. The reason(s) for this are not clear. The purpose of this study is to begin to

understand and explain some of the reasons. I am asking you to help me with a project that

involves an observation study investigating the over-representation of BME in disciplinary

hearings. Observations will be undertaken by the researcher of Trust employees involved in

the disciplinary hearings and/or attend meetings where the over-representation of BME staff

in disciplinaries is discussed.

Attached to this letter are a consent form and a participant information sheet that gives more

details of the study.

If you are interested in participating in the study please return the consent form in the prepaid

addressed envelope, enclosed with this letter, to Harjinder Sehmi by DATE. Once this has

been received I will contact you to discuss the next stage.

If you would like more details please contact HarjinderSehmi on 07768 145528 or

H.Sehmi@sgul.kingston.ac.uk

Yours sincerely

HarjinderSehmi

RECRUITMENT LETTER – Interview

257

Version 2 – 31/10/2012

Date

Dear

The Apparent Over-representation of Black and Minority Ethnic Employees (BME) in

Disciplinary Hearings in an NHS Trust

There is recognition in the Trust of the over-representation of BME staff in disciplinary

hearings. The reason(s) for this are not clear. The purpose of this study is to begin to

understand and explain some of the reasons. I am asking you as a Trust employee involved

in disciplinary hearings and/or attending meetings where the over-representation of BME

staff in disciplinaries to help me with a study. This will involve an interview about sharing your

experiences and thoughts about the over-representation of BME in disciplinary hearings.

Attached to this letter are a consent form and a participant information sheet that gives more

details of the study.

If you are interested in participating in the study please return the consent form in the prepaid

addressed envelope, enclosed with this letter, to HarjinderSehmi by DATE. Once this has

been received I will contact you to discuss the next stage.

If you would like more details please contact Harjinder Sehmi on 07768 145528 or

H.Sehmi@sgul.kingston.ac.uk

Yours sincerely

HarjinderSehmi

Appendix 3: Participant information sheets

258

PARTICIPANT INFORMATION SHEET: OBSERVATIONS

Version 2 – 31/10/2012

The Apparent Over-representation of Black and Minority Ethnic Groups (BME)

Employees in Disciplinary Hearings in an NHS Trust

We would like to invite you to take part in a research study. Before you decide we would like

you to understand why the research is being done and what it will involve for you. I will go

through the information sheet with you and answer any questions you have. Please take your

time to read the following information carefully.

Part 1 tells you the purpose of this study and what will happen to you if you take part.

Part 2 gives you more detailed information about the conduct of the study.

Please contact HarjinderSehmi if anything is not clear and you would like to receive more

information. Take your time to decide whether or not you wish to take part in this study.

The research will investigate the apparent over-representation of BME employees in

disciplinary hearings within the Trust.

Employees involved in the disciplinary hearings and/or attend meetings where the over-

representation of BME employees in disciplinary hearings is discussed are invited to

participate in the research through an observation study.

PART 1

What is the purpose of the study?

The Trust through the superseded Race Equality Scheme, the current Equality and Diversity

Framework and Service and Equality Workforce Report 2012 has recognised that its BME

workforce are over-represented in disciplinaries. The reasons for this are not clear. The

purpose of this study is to begin to understand and explain some of the reasons. 259

Why have I been invited?

You have been invited to take part in this study as you are involved in disciplinary hearings

and/or attend meetings where the over-representation of BME employees in disciplinary

hearings is discussed.

Do I have to take part?

No, you do not have to participate. There will be no adverse consequences in terms of your

employment status if you decide not to participate. If you agree to take part you will be asked

to complete and sign a consent form. You are free to withdraw from the study at anytime,

without giving any reasons.

What will happen to me if I take part?

Once you have consented the researcher will inform you about the date he will be observing

a meeting you are attending where BME employees in disciplinaries is discussed.

Study methods

Observations are a method used to observe, and later analyse, behaviours as they occur in

meetings. For this study the researcher will employ two types of observations: non-

participant observations and participative observations. For non-participant observations the

researcher will be present but will not take part in the meeting. For the participative

observation the researcher will be present in the meeting and will occasionally ask questions

to the group related to the subject investigated. Notes from the observations will be taken by

the researcher and will be used as a part of the data analysis.

What will I have to do?

For the meetings observed by the researcher you will not need to do anything apart from

naturally carrying on as you do in the meeting.

260

What are the possible disadvantages and risks of taking part?

The individual and the group being observed may be distracted with the researcher present

and this may impact on how the individual and the group usually functions. Discomfort may

occur when the subject of BME employees in disciplinary hearings is discussed.

What are the possible benefits of taking part?

We cannot promise the study will help you but the information we get from this piece of work

will help the Trust to understand and explain the over-representation of BME employees in

disciplinary hearings. It may inform future policy, practices and further research.

What if there is a problem?

Any complaint about the way you have been dealt with during the study will be addressed.

The detailed information on this is given in Part 2.

Will my taking part in the study be kept confidential?

Yes. All of the information you give will be anonymised so that those reading and hearing

reports about the study will not know who has contributed to it. The details are included in

Part 2.

This completes Part 1

If the information in Part 1 has interested you and you are considering participation please

read the additional information in Part 2 before making a decision.

PART 2 of the information sheet

What will happen if I do not want to carry on with the study?

If you choose to withdraw from the study at any time no further data will be collected from

you. Any data that has already been collected will remain in the study.

261

Complaints

If you have a concern about any aspect of this study, you should contact the academic

supervisors Professor Helen Cowie and Professor Helen Allan who will do their best to

answer your questions. Contact details are:

Professor Helen Cowie – 01483689726 and H.Cowie@surrey.ac.uk

Professor Helen Allan – 01483689745 and H.Allan@surrey.ac.uk

Address where both academic supervisors can be reached is: University of Surrey, Faculty of

Health and Medical Sciences, Guildford, Surrey. GU2 7XH.

If you remain unhappy and wish to complain formally you can go through the University of

Surrey. Details can be obtained from the Research Office on 01483 689110.

Harm

In the unlikely event that something does go wrong and you are harmed by taking part in this

study, there are no special compensation arrangements. If you are harmed due to

someone’s negligence then you may have grounds for legal action, but you may have to pay

for it.

Will taking part in this study be kept confidential?

All the information that is collected from you during the course of the study will be maintained

in a strictly confidential manner. All names of people and places will be removed and coded.

Pseudo names will be used in the transcription of audio recordings. Your personal details will

be stored in password-protected computers in password-protected files. The offices where

the computers are stored will be locked when the room is not occupied. Signed consent

forms will be stored in locked cabinets in locked rooms. Only the researcher will have access

to your personal details. The personal data will be stored until the end of the study so a

262

summary of the study can be sent to you. After this, all personal information will be disposed

of securely.

The data that has been collected for this study will be stored in a locked facility for 10 years.

Data will be stored securely in accordance with the Data Protection Act, 1998. The custodian

for the data will be HarjinderSehmi.

In the reporting of the project, no information will be released which will enable the reader to

identify participants.

What will happen to the results of the research study?

The results of the study will be written up as a doctoral thesis. A summary of the findings will

be sent to the participants. The results may also be published in academic journals. None of

these publications will reveal the identities of individuals and places who have participated in

this study.

Who is organising and funding the research?

This study is organised by the University of Surrey and no funding has been involved.

Who has reviewed the study?

All research in the NHS is looked at by an independent group of people, called a Research

Ethics Committee, to protect your interests. This study has been reviewed and given

favourable opinion by the Research and Development Department for St George’s University

of London and the University of Surrey Ethics Committee.

Further information and contact details:

If you would like any further information about research, specific information about this

research project, advice as to whether you should participate or are unhappy with the study

you can contact the researcher in the first instance:

263

HarjinderSehmi

Kingston University

Faculty of Health and Social Care

St George’s University of London

Grosvenor Wing

Cranmer Terrace

SW17 0RE

Email: H.Sehmi@sgul.kingston.ac.uk

Tel: 07768 145528

PARTICIPANT INFORMATION SHEET: INTERVIEW

264

Version 2 – 31/10/2012

The Apparent Over-representation of Black and Minority Ethnic Groups (BME)

Employees in Disciplinary Hearings in an NHS Trust

We would like to invite you to take part in a research study. Before you decide we would like

you to understand why the research is being done and what it will involve for you. I will go

through the information sheet with you and answer any questions you have. Please take your

time to read the following information carefully.

Part 1 tells you the purpose of this study and what will happen to you if you take part.

Part 2 gives you more detailed information about the conduct of the study.

Please contact HarjinderSehmi if anything is not clear and you would like to receive more

information. Take your time to decide whether or not you wish to take part in this study.

The research will investigate the apparent over-representation of BME employees in

disciplinary hearings within the Trust.

Employees involved in the disciplinary hearings and/or attend meetings where the over-

representation of BME employees in disciplinary hearings is discussed are invited to

participate in the research through an interview.

PART 1

What is the purpose of the study?

The Trust through the superseded Race Equality Scheme, the current Equality and Diversity

Framework and Service and Equality Workforce Report 2012 has recognised that its BME

workforce are over-represented in disciplinaries. The reasons for this are not clear. The

purpose of this study is to begin to understand and explain some of the reasons.

Why have I been invited?265

You have been invited to take part in this study as you are involved in disciplinary hearings

and/or attend meetings where the over-representation of BME employees in disciplinary

hearings is discussed.

Do I have to take part?

No, you do not have to participate. There will be no adverse consequences in terms of your

employment status as a staff member if you decide not to participate. You are free to

withdraw from the study at anytime, without giving any reasons.

What will happen to me if I take part?

Once you have consented a meeting will be arranged with you to explain the interview

process. A date and time at your convenience for the semi-structured interview will be

arranged. This will be followed by the schedule meeting for you to be interviewed by the

researcher.

Study methods

Semi-structured interviews are a method of study where the researcher has pre-determined

themes to be explored with the interviewee during the interview. Open-ended new questions

will be used to follow up what the interviewee says. The interview will be audio recorded so

the interviewer can engage with the interviewee with minimal distractions. The recordings will

later on be transcribed and analysed.

What will I have to do?

Semi-structured Interview: The interview will be carried out face to face in a room with the

researcher. You will be asked about your experiences and thoughts about the over-

representation of BME employees in disciplinary hearings.

The interviews will take no longer than 45 minutes.

266

What are the possible disadvantages and risks of taking part?

Taking part in the interview will involve your time. Interviewees may become emotional,

particularly if they have been the person disciplined.

What are the possible benefits of taking part?

The information we get from this study will help the Trust to understand and explain the over-

representation of BME employees in disciplinary hearings. It may inform future policy,

practices and further research.

What if there is a problem?

Any complaint about the way you been dealt with during the study will be addressed. The

detailed information on this is given in Part 2.

Will my taking part in the study be kept confidential?

Yes. All of the information you give will be anonymised so that those reading and hearing

reports about the study will not know who has contributed to it. The details are included in

Part 2.

This completes Part 1

If the information in Part 1 has interested you and you are considering participation please

read the additional information in Part 2 before making any decision.

PART 2 of the information sheet

What will happen if I do not want to carry on with the study?

If you choose to withdraw from the study at any time no further data will be collected from

you. Any data that has already been collected will remain in the study.

267

Complaints

If you have a concern about any aspect of this study, you should contact the academic

supervisors Professor Helen Cowie and Professor Helen Allan who will do their best to

answer your questions. Telephone and email contact details are:

Professor Helen Cowie – 01483689726 and H.Cowie@surrey.ac.uk

Professor Helen Allan – 01483689745 and H.Allan@surrey.ac.uk

Address where both academic supervisors can be reached is: University of Surrey, Faculty of

Health and Medical Sciences, Guildford, Surrey. GU2 7XH.

If you remain unhappy and wish to complain formally you can go through the University of

Surrey. Details can be obtained from the Research Office on 01483 689110.

Harm

In the unlikely event that something does go wrong and you are harmed by taking part in this

study, there are no special compensation arrangements. If you are harmed due to

someone’s negligence then you may have grounds for legal action, but you may have to pay

for it.

Will taking part in this study be kept confidential?

Yes. All that is collected from you during the course of the study will be maintained in a

strictly confidential manner. All names of people and places will be removed and coded.

Pseudo names will be used in the transcription of audio recordings. Your personal details will

be stored in password-protected computers in password-protected files. The offices where

the computers are stored will be locked when the room is not occupied. Signed consent

forms will be stored in locked cabinets in locked rooms. Only the researcher will have access

to your personal details. The personal data will be stored until the end of the study so a

268

summary of the study can be sent to you. After this, all personal information will be disposed

of securely.

The data that has been collected for this study will be stored securely in a locked university

facility for 10 years. Data will be stored in accordance with the Data Protection Act, 1998.

The custodian for the data will be HarjinderSehmi.

In the reporting of the project, no information will be released which will enable the reader to

identify participants.

What will happen to the results of the research study?

The results of the study will be written up as a doctoral thesis. A summary of the findings will

be sent to the participants. The results may also be published in academic journals. None of

these publications will reveal the identities of individuals and places who have participated in

this study.

Who is organising and funding the research?

This study is organised through the University of Surrey and no funding has been involved.

Who has reviewed the study?

All research in the NHS is looked at by an independent group of people, called a Research

Ethics Committee, to protect your interests. This study has been reviewed and given

favourable opinion by the Research and Development Department for St George’s University

of London and the University of Surrey Ethics Committee.

Further information and contact details:

If you would like any further information about research, specific information about this

research project, advice as to whether you should participate or are unhappy with the study

you can contact the researcher in the first instance:

269

HarjinderSehmi

Kingston University

Faculty of Health and Social Care

St George’s University of London

Grosvenor Wing

Cranmer Terrace

SW17 0RE

Email: H.Sehmi@sgul.kingston.ac.uk

Tel: 07768 145528

Appendix 4: Consent forms

270

CONSENT FORM – Version 2 (31/10/2012)

The Apparent Over-representation of Black and Minority Ethnic Employees in

Disciplinary Hearings in an NHS Trust

Consent for observations

1. I confirm that I have read and understand the information sheet dated

_____________________ for the above study. I have had the opportunity

to consider the information, ask questions and have had these answered

satisfactorily.

2. I understand that my participation is voluntary and that I am free to

withdraw at any time without giving any reason and without my legal rights

being affected.

3. I agree to take part in the above study.

__________________________ _____________ _________________

Name of participant Date Signature

__________________________ _____________ _________________

Name of person taking consent Date Signature

271

AFTER THE OBSERVATION

I am happy that the data from the observations can be used for this specific

research project.

__________________________ _____________ _________________

Name of participant Date Signature

__________________________ _____________ _________________

Name of person taking consent Date Signature

CONSENT FORM – Version 2 (31/10/2012)

272

The Apparent Over-representation of Black and Minority Ethnic Employees in

Disciplinary Hearings in an NHS Trust

Consent for interview

1. I confirm that I have read and understand the information sheet dated

_____________________ for the above study. I have had the opportunity

to consider the information, ask questions and have had these answered

satisfactorily.

2. I understand that my participation is voluntary and that I am free to

withdraw at any time without giving any reason and without my legal rights

being affected.

3. I agree to take part in the above study.

__________________________ _____________ _________________

Name of participant Date Signature

__________________________ _____________ _________________

Name of person taking consent Date Signature

273

AFTER THE INTERVIEW

I am happy that the data from the interview can be used for this specific

research project.

__________________________ _____________ _________________

Name of participant Date Signature

__________________________ _____________ _________________

Name of person taking consent Date Signature

Chapter 9: Overview of the integration of

knowledge, research and practice

274

9.1 Introduction

This chapter looks at how modules from the taught clinical doctorate facilitated the

final research project. An overview of the key themes that contributed to this study

and how they were integrated are discussed.

9.2 Development of self

The taught doctorate has empowered me to investigate a sensitive and politically

charged area that is under-researched.

Learning is a complex and individual process that incorporates emotions, cognitions

and behaviours. Moving from novice to expert (Benner, 1984) requires a transition

from surface to deep understanding (Ramsden, 2003) and challenging underlying

assumptions that justify behaviours. Reflections become critical when it uncovers the

dynamics in power relationships and when social and cultural hegemonic practices

are critically analysed. The knowledge gained from this tacit region has supported me

to confront, understand and work through an area of inequalities. Critically reflecting

and learning from experience can empower and liberate marginalised groups and

formulate new understanding so inequality and inequity can be curtailed.

The taught part of the doctorate has allowed me to identify with the child in The

Emperor’s New Clothes by Hans Christian Andersen: the lone child in the audience

of a procession pointing out the emperor is not wearing any clothes.

9.3 Advanced research methods

Before attending the course, my knowledge around the different qualitative and

quantitative methodologies was limited. Looking back on my experience around the

master’s programme that I undertook, I often consider the grounding in methodology 275

at the time was narrow and ‘unscientific’. The epistemology of the theory of

knowledge and science provided a foundation to consider the best method I could

draw on to find out about culture and multiple realities that exist side by side.

I was aware of anthropologists going too far away exotic locations and spending

years with their notepads, binoculars and magnifying glass to gather information to

explain the cultures of these societies. Naively, I did not consider that some of the

methods used by these social explorers could be applied nearer to home.

During this module I was quickly drawn to the sessions on ethnography. On further

reading and discussions with staff delivering this module, I came to the conclusion

that ethnography was the best method to explore the over-representation of BME

employees in the disciplinary process in an NHS Trust. I wanted to explore this

phenomenon from the perspective of employees who were directly involved in the

disciplinary process and hear about their subjective realities.

The fantasy I had was quickly challenged and dispelled when designing the approach

I could undertake. The reality of finding and negotiating with a Trust to gain access to

undertake a study was a challenge. Without securing a site, the study could not

happen.

The module gave me a framework to consider what I would be presenting to senior

managers pressurised by time and heavy workloads and how I could use the time

allocated to engage and commence a trusting relationship. The rationale for the

methods I would use to collect data was questioned. In particular, queries were made

about the use of participant observations. Months of negotiations were rewarded with

consent given to undertake the study at the Trust site.

276

Although the taught doctorate equipped me with the tools to carry out the study,

engaging with gatekeepers to discuss how these tools were going to be applied in

their settings was equally important. Having discussions in the class made me

critically reflect on why certain approaches in ethnography were being used and not

others.

The role of preserving ethics and how this is sensitively conveyed without arousing

further anxiety was crucial. As a novice who had never had to go through an ethics

committee, this was a daunting and yet an important learning experience, particularly

around the blind spots that were unexpectedly uncovered. My proposal had been

rejected by the UREC at the first submission. More clarity was needed on how BME

employees who had been disciplined would be protected. The support, experience

and advice from academic supervisors to solve this problem were invaluable.

9.4 Service evaluation

The NHS Trust where I undertook my study has been going through disaggregation

and reconfiguration in order to improve the efficiency and cost-effectiveness of its

services. This module raised awareness of the realities of health economics in the

NHS which has raised discomfort in me and challenged my political stance. The

impact of cost-effective measures to increase productivity with fewer resources and

their consequences on clinicians delivering services has been visible while I have

been collecting data in the field.

9.5 Leadership in healthcare organisations

The summative assignment for this module highlighted how a leader of a public

organisation inconspicuously rationalised white dominance. Leadership in the context

277

of an organisation made me consider what lies under the surface. The unconscious

psychic life and defences of organisations and individuals that are used to avoid

difficult and painful emotions were discussed in this piece of work. During the

collection of data for the final research, I reflected on how people from diverse and

different backgrounds were presented. The category of BME arouses reactions

where the category white is presented as neutral and the norm. My final study

wanted critically to reflect and analyse the norms that preserve the self-interests,

power and privilege of dominant groups. Also, I wanted to move away from the

polarised debate between ‘white versus black’ and consider the differences within

and between BME groups.

9.6 Emotional intelligence

The taught doctorate programme not only developed knowledge but also considered

how emotions are understood and worked with. My subject area involved dealing

with anxiety. The use of self-awareness to understand my feelings during the time

spent in the Trust, meeting employees and collecting data, was constantly checked. I

also considered how I managed myself, particularly when I felt vulnerable. If I felt too

anxious, this would be picked up and have an impact on the dynamics in the

relationships and potentially the quality of data shared and collected. It was important

to consider what others were saying, feeling and why. The use of reassurance was

constantly monitored. There were concerns from senior managers that the findings

could be negative and the Trust perceived as discriminatory, particularly at a time of

making another bid to gain FT status. Undertaking a position of neutrality is not

always easy. Academic supervision has been a space to work through the issues

that have come up.

278

9.7 Policy, politics and power

The phenomenon of the disproportional representation of BME employees involved

in the disciplinary process is politically charged. Undertaking a module on policy,

politics and power enabled me to think about the context, process and content of the

policy-making process which I incorporated into my research.

To understand the data I was collecting, I needed to reflect on the context of the

Trust. Attention in particular was paid to the historical, political, social and cultural

context. BME staff, particularly nurses and doctors, have been rooted in the NHS

since 1948. The cultural behaviours and working practices and how they fitted in with

the norms of the majority made me critically reflect on the imbalance of power.

Critically reflecting on power relationships was important to consider when I was

collecting data. The complexity of what might be going on between the interviewer

and interviewee was analysed. Consideration was given to the gender, race, age,

status of role and class of the participants. Attention was also given to where the

interviews were being conducted. I would ask the participants where they wanted to

meet. Without discussing this openly, this was to reinforce that the participant had

some control and was in a place where they would be comfortable to talk. What was

striking was that senior managers liked to meet in their offices. Rarely did participants

come to the HR department where I was based.

Disciplined BME employees did not participate in this study despite initially showing

interest. Part of the reason was that they did not want to relive the painful experience,

which was understandable. However, trying to reflect how this could be addressed

279

for future studies continues to pose an issue. This issue is raised as the experiences

of these employees have not been integrated into this study. A gap remains.

9.8 Dissemination of the findings

The findings from this study will be summarised and shared with the Trust.

Presentations and discussions will be held. Attention will be paid to how this will be

facilitated to encourage an open and authentic dialogue.

How this study can be developed and consolidated into further research with the

Trust, which has allowed a sensitive subject to be explored, remains to be seen. It is

important that the ethos of this study is embraced and its findings incorporated into

practice.

Concepts and findings will be integrated into teaching sessions with pre- and post-

registered nurses. Undertaking this study informed by the taught doctorate has made

me critically reflect about the quality of training that healthcare professionals,

particularly nurses, receive. It is unclear if issues around poor conduct and

performance are rooted in how nurses are trained and socialised into the profession.

This aspect has been overlooked as the study did not consider the role of higher

education institutions. In collecting data on disciplinaries, the place of training needs

to be considered. As a lecturer involved in the training of pre- and post-registered

nurses, I have become more aware of my responsibilities in supporting and

challenging student behaviour around conduct and performance.

9.9 Conclusion

Key areas of the taught programme that had significance have been highlighted. I

began this course with a lack of depth and inexperience in the research process. 280

Having the opportunity to engage with a process that allowed me to undertake an

under-researched study has been an achievement.

Chapter 10: Research log

281

10.1 Introduction

This research log is the journey for undertaking a thesis to investigate the

disproportional representation of BME employees involved in the disciplinary process

in an NHS Trust. The journey starts with the application made to the university to

undertake a taught doctoral programme and continues to the submission of the

thesis.

10.2 Why I took a taught clinical doctorate programme and not a

PhD route?

Although I lecture at a university, I have continued to undertake clinical work in the

NHS. Mental health nursing and psychotherapy have informed my teaching of

nursing students and qualified nurses. The context of the setting where clinical work

is undertaken has been consistently at the forefront in my thinking, particularly at a

time of continuous political and economic change. Even though patients are at the

centre of the NHS, the quality of care provided depends on how clinicians on the

front line are supported during chaotic times.

By its nature, the taught clinical doctoral programme has allowed me to continue to

focus and keep the clinical work in mind. It has precluded me from engaging with

something abstract and not directly related to the day-to-day realities of working in

the NHS. Modules from the taught element provided a framework, tools and skills to

undertake a study on a sensitive area that few have embarked on.

A valuable part of my learning has been studying with peers. Undertaking a taught

programme allowed me the opportunity to be with other doctoral students. At the start

of the course, there were four of us.

282

10.3 Selecting the subject to investigate

Originally I wanted to develop my Master of Science (MSc) study to a doctoral level.

The area that I examined for the masters programme was why BME patients,

particularly from South Asia living in Britain, did not engage in psychological

therapies such as group psychotherapy. During the literature search, I was distracted

by the disproportional representation of BME employees involved in the disciplinary

process in the NHS. On further investigation, I found that there was a dearth of

studies in this area to explain the reasons for this phenomenon. Studies that

investigated this phenomenon did not consider the experiences and perspectives of

employees directly involved in the disciplinary process in an NHS Trust.

10.4 Framework, tools and skills needed to undertake the study

There was a ten-year gap between finishing my MSc to starting the application to

undertake the doctoral studies. Although I had successfully completed the master’s

programme, I felt out of touch with the rigour of the research process and lacked

some confidence and skills to undertake a major step towards the doctoral level.

The taught element of the course provided a grounding to build the proposal into a

thesis. This started off with epistemology arising from the philosophy of science and

knowledge. The module on policy, politics and power highlighted the politics of

research. The questions of ‘whose truth’ and which groups in society are

marginalised were considered in the study. Issues around multiple realities existing

alongside each other were also taken into account. Policy analysis took into account

whose health and social care needs are met. Confidence was obtained to analyse

the responses from government that were not always as they appeared. Measures

could be rhetorical. This study wanted to look beyond this. The leadership and 283

management component of the taught programme gave an opportunity to analyse

and reflect critically how leaders followed by managers marginalise under-

represented groups without authority been questioned. To advance knowledge,

thought was given to areas that were emotionally charged and how I could be in this

space to reflect critically on what was happening in an emotionally intelligent and

sensitive way to open discourse. Undertaking the assignment for leadership in

healthcare organisations was invaluable. This provided a framework that supported

me to gain access to an NHS Trust and investigate a sensitive and politically charged

phenomenon that was under-researched.

To undertake this task, advanced research methods provided a structure to think

about the approach I was going to use. Qualitative and quantitative paradigms about

the best methodology to investigate the culture and lived experiences of employees

in a Trust drew me to ethnography. This was an approach that I was unfamiliar with

and at the same time excited about. Tools and skills to understand and use the

concepts from ethnography were provided to enter the world of social anthropology.

The service evaluation brought in the economic realities of governments with limited

resources having to make decisions on what health and social care to provide to the

population. The complexity of the world of health economics that I had ignored was

brought to the fore. This area again has been helpful, particularly being in the field

where services have been disaggregated and reconfigured because of the economic

realities.

284

10.4.1 Gaining access to a Trust

The proposed research depended on finding a Trust with a disproportional

representation of BME employees involved in the disciplinary process. Negotiating

permission to gain consent and access to an NHS Trust to undertake a study

involving a sensitive and politically charged subject took longer than the actual time

that was spent in the field to collect data. The gatekeepers were Trust Board

executives and a senior manager. A number of meetings were held to build up a

trusting relationship. Attention to the use of sensitive language was given. Words

such as ‘racism’ and ‘discrimination’ were avoided. Where possible, neutrality was

maintained and assumptions were avoided. Research jargon was avoided and if it

had to be used it was simplified without becoming patronising.

During negotiations, a Trust Board executive wanted me to make amendments to the

research proposal. The title of the study and the size of sample needed to change

before any authorisation would be given. This was carefully considered with

academic supervisors. I was afraid of losing autonomy and authority over my study.

At the same time, with the pressure to complete the taught programme within a

specified time, I was worried I would lose this site after many months of painstaking

negotiations. The changes were adapted to the research proposal and submitted to

the Trust’s R&D ethics committee and the UREC.

Having gained permission to enter the field and collect data, the senior manager,

who had advocated and supported my study, left the Trust without serving notice.

This was a precarious time as I felt vulnerable. I feared the Trust would withdraw its

consent. I managed to collect the data within the time allocated. However, areas and

meetings to undertake participant observations were restricted.

285

10.5 Research process

As a BME doctoral student, I have been aware of undertaking a study that has

involved BME employees who have been treated unfairly and unequally. I have been

particularly mindful of this when BME employees have spoken openly about

colonialism in the interviews. Coming from a country that was under British colonial

rule, I have tried to reflect on the impact of this dynamic on my motivation to

undertake a study of this nature and the impact this could have on the research

process.

There was a dearth of studies on the over-representation of BME employees

involved in the disciplinary process in the NHS. During the literature search, I

struggled to find academic articles. I felt as if I was not doing the search correctly and

had overlooked something in the process. The support of staff from the learning

resource centre from the university and the medical school to help with finding

academic articles was drawn on. They too struggled in finding articles. Trying to link

the findings from the study to the literature review in the discussion, at times, has not

been consistent and thorough.

Initially I was asked to put in an application to the NRES. This was daunting as I have

never had to undertake this process before. Engaging with making an application

was a challenging and confusing experience. After I submitted my application to

NRES, I was informed that I did not need approval from this body as my study did not

cover patients and carers. However, I did need to go through the Trust’s own R&D

ethics committee.

286

Ethical concerns were raised by the UREC about collecting data from BME

employees who had been disciplined. The committee wanted to know how the

confidence and confidentiality of this group of participants would be protected. The

measures that would be taken were clarified.

This study has not been able to engage BME employees who have been disciplined.

Initially employees did express interest but when times and locations of their choice

were arranged to meet, they withdrew. TU officials acting as intermediaries reported

these employees did not want to relive the experience of the event and its associated

emotions of shame and humiliation.

Gaining permission and access to observe a disciplinary hearing was an

achievement, particularly as these hearings are confidential and happen behind

closed doors. The findings from this study have predominantly come from the 27

semi-structured interviews with employees who have been directly involved in the

disciplinary process. Most interviews were audio recorded and lasted approximately

one hour. The interviews were transcribed and then the transcripts were read while

listening to the audio recordings to check for accuracy. Owing to constraints, the

transcribed interview could not be checked with participants for clarification and

follow-up questions. Finding and analysing themes from the masses of data collected

was overwhelming. The structure of the discussion has centred on the findings.

Writing to the critical level of analysis required for a doctoral level has presented

challenges.

287

10.6 Academic supervisors

Having the support and guidance from academic supervisors has been integral in this

process. A lot can be gained from their experience and knowledge. This is not always

used to the optimal level at the time. Taking on board the constructive challenges

presented by supervisors has not always been easy, particularly when agreed action

plans have not been met at timescales set. The realities of not meeting the tasks

have been appropriately discussed in the annual reviews and supervision sessions.

Supervision has been regular and the supervisors have been available between

sessions.

During the journey, unexpected personal events have happened outside the course

that have led to taking time out from the studies. Supervisors have been there to

provide pastoral support. Re-engaging with studies after time away has not always

been straightforward.

10.7 Peer support

I have always gained from the support and experiences from fellow peers particularly

clinicians from previous courses that I have undertaken. At the beginning of the

programme, four doctoral students enrolled on the course. Over time, the other three

students have left the course without completing. Undertaking doctoral studies has

been an isolated and lonely journey at times. Many things have been put on hold.

Relationships with my partner, family and friends have had to be adapted. This has

had an impact on my learning experiences and how I have engaged with the doctoral

process. People who have been on this quest or are going through this process know

what it is like and can identify with the rollercoaster of emotions and demands.

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Others who have not undertaken this journey do not understand. I have missed the

peer support of being in a group, particularly at these times.

10.8 Conclusion

This research log gives an overview of the journey that I undertook. Reasons why I

took the taught doctorate and not the PhD route are touched on. Arriving at the

phenomenon that I investigated came from a literature search around another area I

had set out to undertake. Key areas have been identified, particularly around

securing an NHS Trust to allow me to undertake a study about a sensitive subject.

Without having a site, this study would not have taken place.

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