Journal of Nursing Management, 2006, 14, 52–58

Nurse bullying: organizational considerations in the maintenance

and perpetration of health care bullying cultures

MALCOLM A. LEWIS MA, BEd(Hons), RGN, RCNT, RNT, DN(Lond), FETC, Cert Ed, DHP, MIHM

Senior Lecturer, Department of Health and Postgraduate Medicine, University of Central Lancashire, Preston,
Lancashire, UK

Correspondence L E W I S M . A . (2006) Journal of Nursing Management 14, 52–58

Malcolm A. Lewis
Department of Health and
Postgraduate Medicine
University of Central Lancashire
Preston PR1 2HE
Lancashire
UK
E-mail: MALewis@uclan.ac.uk
Nurse bullying: organizational considerations in the maintenance and
perpetration of health care bullying cultures
Aim: To examine bullying within nursing from a micro-sociological perspective
and elucidate interactive mechanisms contributing to its causes and continuation
within the nursing profession.
Background: The paper is part of a doctoral research study into bullying within
nursing. It considers issues pertinent to management, and in the role of negotiated
interactions within the National Health Service when dealing with bullying prob-
lems. The complex dynamics involved can be problematic for management when
dealing with bullying, while often managers have been targets of bullying them-
selves and not infrequently accused of it. Features of bullying activity are explored,
along with issues of target and bully awareness, a central feature in bullying
negotiations. Issues of awareness and emergence of bullying behaviour have been
identified through vignettes and unstructured interviews, and the research has
identified complex interactive events in the creation and maintenance of nurse
bullying activity. It is hoped that with a clearer understanding of such mechanisms
and manifestations that bullying in the workplace can be reduced or eliminated. The
paper is of practical use to nurse managers in illuminating such mechanisms and
bringing bullying awareness to the fore. Such activity is ultimately damaging to the
organization in both cost and time; and significant for professional practice by its
impact upon the nurse and their work in supportive and safe environments. It will
also to allow managers to consider their own practice and reactions to bullying
activity within the profession.
Conclusions: The overall findings from the research point strongly to bullying
activity being essentially Ôlearned behaviourÕ within the workplace rather than any
predominantly psychological deficit within individual perpetrators and targets.
Keywords: bullying, negotiation, power, resolution, symbolic interaction

Accepted for publication: 8 December 2004

The growth and continuation of workplace abuse bullying are not only detrimental to organizational
within the UK workforce presents as a worrying prob- reputations, but are costly in terms of manpower,
lem. Within health care, and nursing in particular, there investigation times and administrative costs (Einarsen
is growing evidence that the effects of organizational & Skogstad 1996, Aquino 2000, Raynor 2000). Recent

52 ª 2006 Blackwell Publishing Ltd


evidence from the UK health care suggests that up to
85% of nurses were now witnessing or have been tar-
gets of bullying (Hoban 2004). Similar figures were
being quoted for other ÔprofessionalsÕ, i.e. particularly
teachers. Studies of specific organization’s responses to
violent and aggressive acts are not abundant, and in
depth studies on nursing bullying are even more scarce.
The origin of this paper is from the completion of
recent research (Lewis 2004) considering nurse bullying
from both a temporal and interactive perspective, and
examining bullying events affecting both nurse manag-
ers and clinical nurses. It arose both out of personal
interest and experience in handling such events in
practice, which to the author were often resolved
unsatisfactorily to all concerned. The research exam-
ined the perceptions of both clinical nurses working in a
variety of nursing specialisms nationwide, and of the
experiences of nursing managers, again in a wide vari-
ety of nursing specialisms from one large northern
Trust. A series of 20 in depth unstructured interviews
were undertaken (10 with clinical nurses who identified
themselves as being bullied and 10 with nursing man-
agers) following the presentation of four bullying
vignettes based upon established bullying practices
identified from research (Hoel et al. 1999, Hadikin &
O’Driscol 2000). I was anxious to explore how the
meaning of bullying was linked to situation(s) of bul-
lying, and in the emergent self-concepts of both targets
and bullies. This was partly due to the inadequacy of
definitions, which were often variable and contested
within the research (Keashley 1998, Lewis 2002a), so
an in depth microapproach to understanding bullying
events in nursing was felt important. The uniting theme
of Symbolic Interactionism theorists and their emphasis
on the situational context of meaning (Huber 1973);
and the role of meaning as a communicative process
(via symbolization) located in interpretative acts, allows
us to pay particular attention to the uniqueness and
variability of situations and how they reflect attitudes of
mind. This approach seemed particularly suitable in
investigating these nurse’s worlds, and in particular the
complex relationships, which may lead to an under-
standing of bullying’s social construction. The main
reason that bullies appear to remain powerful is
through their ability to impose, in many instances, their
definition of the situation within any negotiative pro-
cesses. ÔDefining the situationÕ or the definition of the
situation explores the behavioural possibilities of situ-
ations and actions. Waller (1961) in an examination of
group definitions contends that many people interacting
in group life have mapped out and influenced pre-
existing definitions of the situation; thus the individual
ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 52–58
Nurse bullying
becomes influenced by such as they become part of the
culture carried by any particular group. Members of
nursing clique groups (a narrow group of people with
common interest) are no exception, and where influ-
enced by dominant or bullying individuals the dominant
definition may take precedence.
Power differentials are a prime concern within bul-
lying interactions and negotiations, and such an
approach may also allow us to elaborate upon and
explain with more clarity the processes which take place
during the perpetration and investigation of bullying
events; and in how such cases are dealt with within the
UK nursing.
The research has also revealed how bullying events
are instigated and sustained within the nursing envi-
ronment, and how the central issue of negotiation
becomes a prime mediator in the formal handling of
bullying episodes by the organization. In line with many
small- and large-scale organizations the principal bul-
lying perpetrator in nursing is often a line manager
(Flynn 1999), which presents us with particular
problems.
Nurse bullying in context
Bullying within nursing is primarily intraprofessional
(i.e. between nurse and nurse). Raynor (2000) suggests
that the National Health Service (NHS) has a complex
organizational profile, not least due to its complexity
and size, representing a myriad of typologies and cul-
tures which in itself leads to differing treatment being
meted out to differing groups. Nurses themselves are
open to such conflicts, and cannot be regarded as a
homogenous professional group. Carpenter (1977)
alludes to mechanisms of professional conflict, enhanced
by a bureaucracy of nursing based upon a single-minded
pursuit to achieve and maintain a cohesive occupational
community. Likewise Davies (1995) sees nurses as
continually striving towards liberation from traditional
opposition. While this in itself may set up conditions for
interprofessional conflict, i.e. between say medicine and
nursing, intraprofessional conflicts are often focused
upon the emergence of conflicting professional sub-
groups and cliques within nursing. Such groups are often
seen as ÔfavourableÕ reference groups for nurses to aspire
to, which may initiate tensions between less prominent
or popular areas of nursing. The development of nursing
clique groups also creates opportunity for the nurturing
and ÔhidingÕ of the nurse bully.
Perpetrators of bullying within nursing exhibit gen-
eral characteristics of bullies in all organizations (see
Table 1 for a general overview). Such groups have the
53
M. A. Lewis

Activity
Deliberate, planned activity to discredit
Bullying acts
Undermining of work,
disadvantaging the target,
physical abuse (rare), verbal abuse,
isolating individuals, interfering in
work practices, continual criticism,
sarcasm, demeaning, destroying
confidence, fabricating complaints,
setting up to fail
Bullying awareness
In cases of bullying the bully is
invariably aware of the damage
they are doing. They undertake such
actions basically to gain control and
power. In cases of ÔunwittingÕ bullying,
if such actions are brought to the
perpetrators attention they should stop
Time frames
Bullying events vary in their length
(the research has identified cases
ranging from 6 months to 7 years)
Table 1
Comment
Some features of bullying activity
The majority of bullies are fully aware
(Lewis 2004)
of their actions. They are devious and cunning;
but may exhibit a ÔJekyll and HydeÕ mentality.
A percentage of bullies exhibit personality problems
Comment
Such acts are frequently insidious, and continue
over periods of time. They frequently occur
Ôbehind closed doorsÕ, are difficult to pinpoint and
often occur with no witnesses
Comment
Target awareness is complex. Nurses frequently
do not identify bullying early. It is often seen as a
retrospective event, or where a Ôtrigger eventÕ signals
awareness; i.e. where an outsider, often a colleague
alerts the nurse to it, or a major abuse has taken
place which brings it out into the open.
Targets should in particular note frequency and
intentionality of events
Comment
Targets of bullying can experience prolonged abuse,
and extended recovery periods even after the event
has finished. Examination of bullies within the
workplace often reveals (some 90%) evidence of
Ôserial bullyingÕ. A history of such acts can be
therefore traced to the one individual on
multiple occasions

power to admit and exclude members and enhance their
Ôdefinition of the situationÕ. Nursing clique groups are
no exception where influenced by a bullying individual.
Within such a climate the nurse’s own professional
agendas may also be in conflict with the compelling
demands of others; notably those of general manage-
ment. Aquino (2000), in an analysis of workplace vic-
timization and management styles, expounds on typical
ÔvictimsÕ of bullying, where organizational bureaucracy,
power differentials and competition exist. In particular
where organizations are high in problems and time
pressures, role ambiguities may manifest and managers
in particular may Ôpass the buckÕ, or manipulate such
situations to their advantage.
Bullying awareness and definition
Within the act(s) associated with bullying my research
has made a close examination of bullying awareness
from the views of both targets and nurse managers (as
principal perpetrators). A re-evaluation of Awareness
Context Theory was undertaken (Glaser & Strauss
1965), revealing particularly strong evidence of pre-
tence and manipulation on the part of the bullies.
Examples of such manipulation and pretence were
manifest throughout the bullying process from its
instigation to resolution phase. This can take many
forms, from the act of deliberate lying, to focusing
blame on the target, denying being involved in bullying,
or manipulation of context and procedure during any
investigation. Within nursing definitions of bullying,
and the understanding surrounding its complex
mechanisms remain confused; thus the ability to iden-
tify, let alone deal adequately with cases often becomes
seriously flawed. Both managers and nurses rarely refer
to bullying in the early stages of such conflict. Indeed
everyday conflict is seen more as a normal part of the
job, and is therefore tolerated by most nurses. It is only
late into most bullying events, often after a significant
event or ÔtriggerÕ has been activated that an accusation
of bullying is made. Such trigger events are frequently
abusive episodes, which may be very public, i.e. an
altercation between bully and target. The interviewees
reveal that quite often bullying events are brought to the
nurse’s attention by colleagues who may have observed
such behaviour over a period of time and alert the
individual to take action. It is often with hindsight that
the definition is made, and frequently a catalogue of
abuse can be identified over a prolonged period. This
contributes to definition difficulties, but I contend from
my findings that a focus on both intentionality (bullying
being a deliberate act by the perpetrator) and frequency

54 ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 52–58


need particular consideration by management. Many
bullies often have a history of ÔserialÕ bullying and target
abuse, with previous complaints made against them.
Nurse managers find themselves in a catch 22 situ-
ation in that in many cases managers not only engage in
bullying activity, but are also the targets themselves.
Managers relate that this targeting essentially comes
from more senior managers, but there is also peer bul-
lying, and even more prevalent subordinate bullying
from nursing teams or staff groups, particularly if
decisions are unpopular or the manager is new. This last
point is of importance, as a number of studies point to
bullying actions as being predominantly a result of
personality defects, i.e. a Ôbullying personalityÕ or indeed
Ôtarget personalitiesÕ of so-called victims (Randall 1997,
Hayle 2000). While individual personality has
undoubtedly a role to play in such actions I contend that
such issues are predominantly contextually (workplace)
mediated. Indeed, the defective personality explanation
may prove particularly difficult to sustain when many of
theses managers are both perpetrators and targets, often
at the same time. Managers within nursing are often
faced with competing interests between professional
ÔnursingÕ matters and wider managerial concerns;
anxieties, uncertainty and power struggles within a
climate of continued change (Lewis 2004).
Within such a framework the policies and procedures
within the NHS to deal with bullying (mainly in NHS
Trusts) while increasingly comprehensive can also be
confusing and daunting. An inordinate amount of time,
effort and distress appears to be experienced by targets
in gaining redress. My findings indicate that the
experiences of many nurse managers towards bullying
events are overwhelmingly negative. In many instances
use of established policies on harassment, and on the
use of grievance procedure fail to be effective in dealing
with bullying; not least as they are directed through line
management, a major problem if they Ôdo the bullyingÕ.
One consequence of this confused picture, and of
benefit to the bully, is that most bullying events are
Ôkept localÕ as much as possible, i.e. managers attempt
to keep issues contained. While this is desirable in many
cases where a situation can be dealt with adequately
and competently, tactics of local ÔmediationÕ often sends
the wrong message. Others may perceive that com-
plaints are not taken seriously or procedures by passed.
More essentially it totally fails to deal with the bullying
problem and contributes to its hidden nature. As Field
(1996) maintains, in cases of serial bullying events may
cease for a short while, but invariably begin again. The
common tactic of moving targets of bullying from the
source of trouble, when the real source of the problem
ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 52–58
Nurse bullying
the bully Ôstays in placeÕ, fails to deal with the root of the
bullying problem. There needs to be, in many cases, a
total review of policy and procedure, and in particular
evaluations of the effectiveness of any specific anti-
bullying procedures. Namie (2000), at the American
Workplace Bullying and Trauma Institute, in an ana-
lysis of 200 completed surveys of workplace bullying,
found some 80% of cases perpetrated by bosses; but
many targets who tried to obtain redress within their
workplace made themselves more of a target. In par-
ticular, Human Resource Departments often failed to
support targets. In only 7% of the cases was the bully
transferred, punished, or their employment terminated.
Within nursing, witnesses to such acts face a difficult
dilemma. Support from colleagues is often non-existent,
as many fear also becoming a target, or are concerned
for their own position and career advancement, i.e. they
do not want to be seen as trouble makers. Targets in
such situations face an uphill struggle for redress.
The power and negotiative game
The social construction of bullying behaviour remains a
detailed and complex issue. I have questioned the over
emphasis on Ôpersonality variablesÕ, and on identifying
bullying and target types, Field (1996), and while of
heuristic value they singularly fail to explain the
explosion of bullying behaviour in the nursing work-
place. Again the contention that the bully is often a
ÔweakÕ individual is a somewhat outmoded concept;
most bullies are highly articulate and are more than
aware of what they are doing (having said that such a
notion may be valid in a certain percentage of cases; but
my argument remains is this is not a primary cause of
such events). Indeed, bullies are quite able, in many
cases to manipulate contexts and play the power game
to their advantage. The most probable reason for this is
the development of Ôlearned behaviourÕ within the
workplace (Lewis 2004). While there is evidence to
support the notion of childhood bullies developing into
workplace bullies this is not always so (Sutton et al.
1999), as many individuals who had exhibited such
behaviour as a child do not do so later. Raynor (2000)
has given a figure of 1 in four nurses having either
witnessed bullying at work, or becoming targets of it.
This is a worrying figure, and this again casts doubt on
the defective personality theory. Indeed I contend that if
such professionals were defective in this way then it
would have serious implications for our methods of
recruitment and selection of nurses.
What becomes particularly intriguing from an inter-
actionist’s perspective is the socializing effect of the
55
M. A. Lewis
organization, the reinforcement of the dominant defi-
nition of the situation, and so-called Ônorms of beha-
viourÕ and acceptance of the same by so many. This has
been demonstrated in my study particularly when tar-
gets have attempted to gain redress and either been
ignored, or their concerns marginalized or frequently
labelled as Ôpersonality clashesÕ. Indeed I was reliably
informed by one Director of Nursing that it would be
difficult to talk to her managers as they were too busy,
and that anyway bullying did not exist in her Trust. It is
also important to be aware of the continuing criticism
and blame culture propagated essentially by central
government towards sections of public sector employees
(i.e. health care staff, the civil service, etc.); particularly
where targets or initiatives are not met (Lewis 2002b).
This created a general feeling in both managers and
clinical nurses that the current increase in workloads
are also a major contributory factor to the increase in
stressors and bullying activity. Some nurse managers in
my study even advocate the use of ÔbullyingÕ as an
established method of getting work done by staff. In
some situations managers have been aware of problems
for a considerable period of time, and even when
investigations have got underway a number of nurses
have complained of managerial manipulation during
investigations and the ÔrailroadingÕ through of new and
formal procedures as part of a managerial agenda.
While managers may be ethically bound to ensure
appropriate standards of conduct and indeed confiden-
tiality, the actions of some health service managers in
their dealings with workforce bullying abrogate such
responsibilities.
Many bullying situations, as Karpin (1995) main-
tains, are handled very badly. The bullied, on the whole,
are presented with considerable disadvantages when
trying to deal with the bullying event. In a profession-
ally saturated organization such as the NHS the most
power, and therefore control, could be seen to be
invested in its most powerful members. Such control is
manifestly seen in the commitment to organizational
objectives and philosophies, primarily politically driven,
and executed increasingly through management as a
dominant group. What becomes important are the
negotiative processes which sustain such actions; pro-
cesses essentially representing the struggle and resist-
ance between such senior and subordinate groups. In
our case the nurses (those being bullied) and nurse
managers who are enmeshed in a complex negotiative
process in order to accompany their individual purpose.
Understanding how nurses interpret and react to
bullying is essential to understanding how bullying is
dealt with and what actions are made explicit; however,
56
this becomes particularly difficult in the case of the
nurse managers who have conflicting roles. A Symbolic
Interactionist view of organizations sees them as being
essential to the definition of patterns of individual
conduct; but only so in a broad sense as they also allow
for individuality and flexibility. Within such organiza-
tions, and in the taking of roles there are conditions set
on activity, but importantly such conditions do not in
themselves determine it.
As Becker et al. (1961) have pointed out, people
make choices which may limit future choices, and even
where the organization provides relatively fixed sets of
symbols people still use them to interpret situations.
When however, such lines of action join with other lines
of action a social organizational matrix is created. The
importance of such a matrix remains crucial in helping
illuminate the predominant day-to-day activity of the
nurse in the health care environment; and importantly
for identification of their relationships in the bullying
event. From this interperativist standpoint the organ-
ization can be understood and elaborated on, at least
according to the later work of Strauss et al. (1963), not
as a stable force where order is automatic, but as one
where order is reconstructed continually. He points to
disjunctive careers, occupational segmentation, differ-
entiation in professional training and incomplete rule
structures which are constantly leading to the creation
of situations for which negotiation needs to take place.
Bullying is a prime example of this, and an arena for
such activity; organizations therefore get things done by
negotiation. This can be particularly destructive where
situations of unequal power predominate (as within
bullying events) where powerful, often managerial
groups begin to impose their definition of the situation.
A classic example of this is Munday’s (2003) study of
manipulation of bulling events by procedural abuse
within the educational sector. Munday (2003) examines
how this was accomplished by liberal ÔinterpretationÕ of
established disciplinary procedure. The negotiative
context is skewed predominantly in favour of the bully
perpetrator in his study, and in Munday’s (2003, p. 4)
own words Ôthereby ensuring the likelihood of justice is
significantly diminishedÕ. Such strategies, particularly
between workers (i.e. bullied nurses) and management
also involve organized groups, i.e. be it nursing clique
groups, nurse managers, general management or
unions amongst others with vested interests and varied
agendas.
An essential meaning of bullying governs how others
react to it, and indeed how differing groups may or may
not share common understandings; for meanings are
not ÔfixedÕ. As meanings are not fixed both managers
ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 52–58

and nurses have Ômeaning problemsÕ and the potential
for the development of a Ômeaning setting crisisÕ. This is
compounded in nurse managers who have both a
commitment to managerial ideals while frequently
having to maintain a ÔclinicalÕ face of competence. This,
at the start of any negotiation, is made worse by the fact
that definitions of bullying remain contentious; not
prominent in the nurse’s thinking, and with often nurse
managers having little or no training in handling it. I
suggest that before any negotiation surrounding bully-
ing events or attempts at resolution the following
should be at least considered.
• All parties within the negotiative process have goals.
The ultimate goal should be to eliminate bullying in
the workplace; but this a remote possibility in total-
ity. Out of goals, however, flow society’s values, i.e.
towards bullying; but here there are also contradic-
tions, belief systems and political behaviours. This is
particularly true of the NHS. What makes the pur-
suance of goals particularly difficult in the NHS is the
impact of a highly differentiated structure and the
influence of specialized groups and individuals. Those
who have the power to define (negotiate) organiza-
tional goals, i.e. predominantly and increasingly so
managers, may well cloak their own interests in terms
of wider collective organizational goals to influence
their negotiations. Indeed, we see this in Ôrule bend-
ingÕ, and lack of decision making for fear of possible
censure themselves; and in the dubious handling of
many bullying ÔhearingsÕ. Rule bending and manipu-
lation can take many forms, from the hiding of
patient’s notes and subsequent altering of them by a
bullying midwifery manager (a recent case brought to
my attention), to a manager faking information or the
distribution of Ônegative informationÕ regarding an
individual to show them in a bad light.
• Stable limits to what can be negotiated are posed by
the administrative and task structure of the organ-
ization, but this is variable depending upon the nature
of the institution (i.e. Acute Hospital, Primary Care
Trust, whatever). The very structure itself is being
continually negotiated, and thus the structure con-
tinually Ôappears and disappearsÕ to accommodate
differing phases of negotiative processes. This in
bullying situations gives an opportunity for those
with power to further manipulate conditions in their
favour. Bullies are often manipulative, are usually
Ôorganizationally astuteÕ in their knowledge of regu-
lations and loopholes, and may well have been in a
similar position before, all contributory to their
power base. Daniels (1975) in a discussion of
ª 2006 Blackwell Publishing Ltd, Journal of Nursing Management, 14, 52–58
Nurse bullying
professional expertise also alludes to the issue of
professional power which in itself implies an element
of control, but this too varies in its usage depending
upon the social organizational conditions at any one
time. In bullying, and in particular where professional
union representation of the bullied takes place, pro-
fessionals may be able to ÔslipÕ into conditions where
they possess overt coercive power to influence nego-
tiation. The role of the unions can be very variable in
their handling of bullying events, and is dependent a
great deal upon the skills of the individual union
representative.
• Strauss and Bucher (1961) contend that the negotia-
tive process is more likely to be overt in professional
organizations (typical of the NHS) while being more
covert in Industrial Organizations. The fact that
professional activity in the NHS may be Ômore on
viewÕ is a factor here, but I contend in bullying situ-
ations the reverse is true. The negotiative process is
hindered (to the detriment of the target) by the poor
support he or she gets, particularly once a hearing gets
underway. Professional support is poor as is collective
support, i.e. from other work arenas such as general
management. We also see that the professional
ÔactionsÕ by the bullied nurse (i.e. in the pursuance of
their day-to-day work with patients) is predominantly
shielded from the impact of bullying behaviour; it is
hidden, and a demeanour of professional normality is
seen in the majority of cases. Below I propose a
number of elements based on my research, which may
be conducive to effective negotiation. I do not contend
that the list is exhaustive, but if we consider the atti-
tudes of both parties we can see within the bullying
event why they may be difficult to achieve.
Elements conducive to effective bullying
negotiations
• The avoidance of trouble.
• The avoidance of illness.
• The avoidance of litigation.
• The avoidance of damage to reputation (and Ôgag-
gingÕ).
• The avoidance of poor working practices (resentful
staff).
• The avoidance of being called a trouble maker.
• The avoidance of being Ôlabelled and rocking the
boatÕ.
In all bullying cases a majority of these conditions
may not be realized, both for the target, bully, or the
57
M. A. Lewis
organization and thus often disagreements are ÔmaskedÕ
or sensitive issues avoided. There are within such a list
problems for both the organization and the investigative
group, but the potential negative effects on targets is far
greater. Target effects, i.e. both stress and the mani-
festation of physical symptoms, i.e. insomnia, digestive
disturbances, etc. often remain long after the termin-
ation of bullying episodes; resulting in prolonged dis-
ability and in many cases nurses leaving or being forced
out of their job. It has been a continual theme
throughout my research that it is the bully’s manipu-
lative actions, which remains central to such issues, and
can be a major factor in negotiation. Once this is real-
ized then the bullying event can be tackled. Bullying by
managers is in direct contravention of the NHS
Managerial Code of Conduct (2002). Likewise failure
to deal with bullying episodes may amount to a breech
of trust and confidence, and a failure of duty to care.
While no specific bullying law exists as yet in the UK
bullying may give rise to a variety of legal challenges,
not least criminal liability (Porteous 2002) and violation
of Health and Safety legislation. Managers should
realize bullying is incompatible with a Ôno blameÕ cul-
ture and undermines professional accountability. It
needs to be a prominent Ôzero toleranceÕ issue.
Acknowledgements
This research has been undertaken under approval of the
Faculty Research/Ethics Committee of the Department of
Healthcare Studies, Manchester Metropolitan University; and
a large northern Acute NHS Trust.
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