Mid-Staffs and the Bystander Effect

An article in Health Service Journal about Leadership in the NHS post-Mid-Staffs got me thinking about some of the psychological processes that must have been going on amongst staff at the time.

Mid-Staffs has become a by-word for appalling care in the British health system.

Hundreds of patients died needlessly as the Trust which ran the hospital channelled its efforts and energies into becoming a Foundation Trust – a status which gives Trusts more autonomy.

One of the themes of the Francis Report into the scandal (quoting the article author Chris Gordon of the NHS Leadership Academy) is that the Trust was “a failed organisation with a corrosive culture, focused on delivering unsustainable short-term savings to achieve a title and external approval – the cost of which amounted to the systematic neglect of patients’ needs. A weakness of leadership allowed staff to disengage from their responsibilities, turn a blind eye or walk on the other side.”

Now, we all like to think of ourselves as individuals of a certain moral fibre, able to judge right and wrong in any given situation. We’d also like to think that we’d be the one to speak out and act if we saw wrong-doing or people suffering.

The truth is: our behaviour is highly influenced by how others behave. There is a general human default to ‘fit in.’ We are social animals and for some of us our survival instinct is closely meshed with being part of the troop. Fear of expulsion or disgrace is social death. Much better to tailor our behaviour to group norms than to stand out from the crowd and risk opprobium and ignominy.

We have seen many examples throughout history (Nazi Germany being the uber beispiel) of perverse cultures moulding individual behaviour, rewarding conformity and punishing dissent. In advertising, the example is inverted – those rebel children with the hair gel being expelled from their conformist communities.

One of the psychological manifestations of this need to conform is called the Bystander Effect. This states that fear of embarrassment (or other socially negative responses) is more likely to determine our behaviour in a group situation.

I love to quote a couple of well-known psychology experiments that demonstrate the Bystander Effect. One is by Latane and Darley from the 1970s when they had a few people in a room filling in a questionnaire then began filling the room with smoke. The subjects in the group setting took far longer to respond to what could have been a dangerous situation. Afterwards they confessed they were freaking out ‘inside’ but because no-one else was reacting they didn’t react either.

The other example, by Darley and Batson, involved seminary students who were told to prepare a speech on the parable of the Good Samaritan. They were then asked to fill in a spurious questionnaire. Some were then told they were late to give their speech in another building; others were told they had plenty of time. Along their path to the other building, an actor was slumped over and groaning, pretending to be sick and in need of help. Of those seminary students with plenty of time, around 60 per cent stopped to help the man. Of the ones in a rush, only 10 per cent helped, some even stepped over the actor on their way to give their speech.

So, while it’s of no comfort to those who suffered at Mid-Staffs or to their relatives, our human propensity to ignore smoke because it no-one else is reacting to it is equivalent to ignoring harm and poor care because no-one else is reacting to it. We quickly adapt to bad environments and perverse cultures.

In the example of the seminary priests (and don’t you just love the irony of the Biblical text they were asked to base their speech on?) there is another human behaviour – inattentional blindness – which describes the events at Mid-Staffs pretty well. This posits that when we are engaged in a task we tend to ignore all other data that does not contribute to the processing and outcome of the task. This was probably true at an individual level but was definitely true at the corporate level (the Trust’s obsession with jumping through financial hoops and its ignorance of the distress signals from patients, carers and (some) staff) and at the systemic level (Government, regulation etc) where financial concerns were prioritised over quality of care and patient safety.

One would hope that events like those at Mid-Staffs will not reoccur. The HSJ article focuses on Leadership as the space where systems and processes are designed to get the best out of people. Improving the quality of Leaders in the NHS is therefore paramount.

Ref: HSJ, 3 May 2013.