Examining the disciplinary process in nursing: a case study approach

Examining the disciplinary process in nursing:a case study approach

■ Hannah CookeUniversity of Manchester

ABSTRACT

This article examines the disciplinary process in nursing using data drawn fromqualitative cases studies carried out in three healthcare Trusts in the north ofEngland.The main method of data collection employed in the cases studies was indepth interviews with managers, nurses and trade union representatives.The studyconsiders the models of discipline employed by managers when making the deci-sion to discipline, the conduct of disciplinary cases and their outcomes.The studypays particular attention to ‘quasi-formal’ discipline in which investigative processesmay be used as punishments.The study also considers the poor outcomes of dis-ciplinary action and their relationship to the ways in which disciplinary processesare conducted.

KEY WORDS

employee discipline / nursing discipline / professional misconduct

Introduction

ince the 1990s a series of public inquiries in the UK have dealt with casesin which health professionals were found to have harmed patients(Clothier, 1994; Kennedy, 2001). This has led to policy consensus regard-

ing deficiencies in the self regulation of health professionals. Professional regu-lation is said to have taken place ‘behind closed doors’ (Rosenthal, 1995) withfailures in both the stringency and transparency of the process. Professional reg-ulation has, according to the Department of Health, to become ‘tougher, swifterand more open’ (DOH, 2001). This policy consensus has resulted in reform of

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professional regulation with emphasis on greater lay representation and moreexplicit procedures for dealing with the ‘incompetent’ professional. In this cli-mate there has been a steady increase in the numbers of complaints againstnurses rising from 893 in 1996–7 to 1460 in 2003–4 (NMC, 2004a).

Regulatory bodies have no powers of inspection: cases result from com-plaints. Complaints may come from the police, employers, colleagues or mem-bers of the public. In nursing, by far the largest group (60%) come fromemployers and follow the employer’s own disciplinary case, with the secondlargest group following police cases (NMC, 2004b). While court proceedingsare transparent, the employee proceedings which lead to complaints to theNursing and Midwifery Council (NMC) are not open to public scrutiny and welack any reliable data concerning their distribution and prevalence.

The only area of disciplinary activity at Trust level about which we havesome knowledge is suspensions. High profile cases of doctor suspensions haveled to investigations into the use of suspensions by the NHS. For example thecase of Dr Bridget O’Connell lasted 12 years, costing £600,000, yet wasresolved when all the allegations against her were withdrawn (Public AccountsCommittee, 1995). More recently, a number of prominent cases, such as the‘crouton surgeon’, suspended for allegedly not paying for a second portion ofsoup in the staff canteen, have raised the possibility that some disciplinaryaction may be inappropriate (Carvel, 2004). Suspensions came to public promi-nence as a result of the high cost of doctor suspensions, leading to investigationsby both the National Audit Office (NAO, 2003) and the Public AccountsCommittee (1995, 2004).

The NAO report showed that between April 2001 and July 2002 over1000 clinical staff were suspended from the NHS at a cost of at least £40m perannum. The report suggested that suspensions were used inconsistently andpoorly managed. ‘Unnecessary exclusions or cases where clinicians considerthey have been driven out of the health service are of concern both in terms ofpersonal fairness and equity and waste of scarce resources’ (NAO, 2003: 2).

The NAO report led to new guidelines on the suspension of doctors (DOH,2003). The Public Accounts Committee (2004) has expressed concerns aboutcontinued deficiencies in the management of suspensions, including the fact thatnew guidelines apply only to doctors. The NAO report (2003) shed some lighton the prevalence of suspension among other health workers. Reports fromorganizations supporting suspended health professionals have highlighted mis-management of suspensions and their high personal cost. Rates of depression,suicide and myocardial infarction are reportedly high among suspended healthworkers (Fagan, 2004; Tomlin, 2004). These reports raise some serious ques-tions about the conduct of disciplinary cases in NHS Trusts that have not yetbeen answered.

Thus, discipline in healthcare has been largely interpreted through modelsof professional regulation and public protection. The concern with public pro-tection has led to the dominance of a ‘bad apple’ model of professional disci-pline focused on the detection, treatment and/or removal of deviant individuals

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(DOH, 2001). Approaches to nursing discipline have been shaped entirely byanecdotal literature (Pyne, 1998) and by inquiry reports following notoriouscases (Clothier, 1994). We have some limited data on suspensions but, in gen-eral, health service employers’ conduct of disciplinary cases has not been stud-ied. There has been little consideration of how managers discipline nurses orwhether disciplinary action is appropriate and fair.

There has thus been very little interest in the organizational context of dis-ciplinary activity. Questions about how health professionals come to be disci-plined have simply not been asked. To ask these questions we need to turn tostudies of discipline in other industries.

Models of discipline

In the early 1980s some psychologists argued that there had been an assump-tion that employees are more likely to respond to positive rewards than nega-tive sanctions and that, as a consequence, the organizational uses of punishmenthad been neglected. To put it simply, discipline was a matter of carrots andsticks and the use of the stick had been underrated. Thus, during the 1980sthere were attempts to rehabilitate punishment as a disciplinary tool inspired bybehaviourist psychology (Arvey and Ivancevich, 1980; Sims, 1980). This fittedthe political ethos of the time and can be seen as coinciding with the start of theneo-liberal era characterized by an erosion of employment rights and a reasser-tion of the manager’s ‘right to manage’ (Ackroyd and Thompson, 1999).

Existing studies of the disciplinary process have addressed two relatedquestions. The first question is: How discipline is administered? This focusesattention on the rule enforcers, their perceptions of rule infringement, how thedecision to discipline is made and how it is carried out. The second question is:What is the effect of disciplinary action on the disciplined individual and thesurrounding workforce?

Despite an increased interest in the use of negative sanctions among someorganizational psychologists, much sociological literature in this field has beenheavily influenced by Foucault (1977) and has concentrated on the manufactureof consent through the creation of the ‘self disciplining subject’ (Miller andRose, 1990). As Ackroyd and Thompson (1999) have argued, this has under-estimated the continuance of organizational resistance and misbehaviourthrough its representation of workers as ‘docile’ subjects. Arguably, this focuson winning hearts and minds has also taken manager’s own accounts of theirpractice at face value and has underestimated the degree to which coercion andpunishment have remained important tools in the creation of a docile work-force. Thus, according to Knight and Latreille (2000), the creation of high com-mitment workplaces has had little or no impact on formal sanction rates.Knight and Latreille found a steep upward trend in unfair dismissal claims, withunion presence having the most important influence on sanction rates.

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There have been some attempts by sociologists to answer the question ofhow discipline is carried out and categorize models of discipline employed bymanagers. Gouldner (1954) identified three patterns of industrial bureaucracy,which he described as mock, punishment-centred and representative forms.These differed in the number of bureaucratic rules and the manner in whichthey were enforced. Punishment-centred bureaucracies were said to engenderconflict. Henry (1987) has distinguished four models of workplace disciplinedrawing on the work of Gouldner:

Punitive-authoritarian discipline

This is ‘rooted in the master–servant relationship of the feudal era’. Rulesare generally negative and deviance is seen as ‘a deliberate and often per-sonal challenge to authority’. Thus: ‘failure to obey orders, inappropriatemanners and dress and negligence are considered equally as offensive astheft and damage to property’ (Henry, 1987: 284). Procedures for admin-istering discipline are simple and direct and are often hierarchical with noconsultation with subordinates. Sanctions aim at retribution, public humil-iation and deterrence; punishment is harsh and irregular and includes sum-mary dismissal, severe reprimands and public shaming.

Corrective-representative discipline

This involves a more instrumental approach to discipline, emphasizingwritten procedures, an investigation of the case, a hearing with a right torepresentation, progressive sanctions and a right of appeal. Formalized sys-tems incorporating rights to representation and procedural justice areintended to secure legitimacy for disciplinary actions and minimizeemployee grievance and unrest. According to Henry (1987), there is a riskthat this model of discipline delivers ‘less justice than legitimation’. Despitethe right to a hearing and representation, the outcome is often predeter-mined. Sanctions are intended to improve future behaviour but formalizedsystems may lead to employee frustration rather than acquiescence if theresult is seen as a fait accompli. Sanctions are employed progressivelyincreasing through verbal and written warnings to transfer, demotion andultimately dismissal. Dismissal is seen as a last resort. Most formal policiesconform to this model (ACAS, 2003).

Accommodative-participative discipline

In this model discipline is seen to be the result of negotiation betweenworkers and employers. Rules are created to serve the interests of both par-ties (for example, safety rules). Sanctions are subject to bargaining between


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managers and employee representatives. Outcomes are often a compromisebetween respective interest groups.

Celebrative-collective discipline

This emerges in cooperative forms of work groups. Rules are largely basedon unwritten shared values. A central problem in cooperative work groupsis individual failure to participate in the group and inequality of workeffort, the so-called ‘free rider’ problem. Sanctions are informal and aimedat reminding the individual of his/her responsibility to the group. Sanctionsinclude disapproval, shaming and expulsion from the group.

Henry (1987) suggests that although corrective-representative discipline isthe most common formal mode of discipline in the workplace we cannotassume that this is the only model employed. He acknowledges the widespreaduse of informal sanctions. There may be a big difference between what institu-tions do and what they say they do. There is good reason to believe that manydifferent models occur simultaneously in a single institutional setting.

Other writers distinguish between punitive and corrective approaches(Edwards and Whitston, 1994). These two approaches fit closely with Henry’sfirst two models of discipline. Fenley (1998) distinguishes punitive, correctiveand revisionist approaches. Revisionism combines correction and punishmentand Fenley uses the term revisionism to describe the US model of progressivediscipline, which masks punishment behind a rhetoric of correction. Thus,employees are not dismissed but ‘given the opportunity to leave’. Rollinson etal. (1997) distinguish between rehabilitation and retribution (which correspondto corrective and punitive approaches) but, also, introduce a third category ofdeterrence. They argue that deterrence is the most common philosophyemployed by managers. Although conceptually different from retribution it issometimes difficult to distinguish in practice. Deterrence aims to ‘highlight theadverse consequences of any future rule transgression’. Deterrence depends onmanagers’ assumptions of cause and effect. It allows punishment to be ratio-nalized as having a corrective effect. The deterrence philosophy assumes that‘most discipline consists of a rather crude use of psychological conditioning’(Rollinson et al., 1997).

Effects of discipline

I noted earlier the widespread belief that rewards are a more effective form ofcontrol than punishment. This raises a host of questions about the efficacy ofpunishment as a corrective to undesirable behaviour. Does the crude use of psy-chological conditioning employed by many managers actually work? Two factorswhich researchers have hypothesized will have an effect on disciplinary outcomesare the way in which discipline is carried out and its perceived fairness.


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Studies that have looked at the manner in which disciplinary action is car-ried out have concluded that harshness and the expression of negative emotionsare associated with poor outcomes (Greer and Labig, 1987; Rollinson et al.,1997). Harsh discipline which is accompanied by hostility and attempts tohumiliate the employee engenders considerable resentment and compliance issuperficial and motivated by fear. Furthermore, harsh discipline can have effectsfar beyond the individual concerned and can foster a more widespread sense ofgrievance in the workplace (Fortado, 1992).

Positive outcomes, then, are associated with discipline which is carried outin a friendly manner and which addresses itself to the correction of specificbehaviours. Negative management behaviours include destructive criticismwhich involves the expression of negative affect and attributes poor perfor-mance to failings of character and ability intrinsic to the individual. Baronfound that destructive criticism had negative outcomes tending to exacerbateworkplace conflict and undermine self-confidence and task performance(Baron, 1988).

Several studies have noted the influence of perceptions of procedural justiceon task performance (Ball et al., 1994). There have been some attempts toassess factors affecting disciplinary fairness with Fandt et al. (1990) detecting a‘liking bias’. When discipline is believed to be unjust it holds little legitimacywith the workforce and may encourage future rule breaking (Rollinson et al.,1997). It undermines the managers’ claims to exercise legitimate authority. Theimpact of unjust punishment on bystanders is particularly important. Unjustdiscipline has been said to have widespread effects, lowering morale andincreasing rates of attrition (Trevino, 1992).

Some recent qualitative studies have suggested that perceived or actualunjust discipline may be widespread. Rollinson et al. (1997) studied 44 employ-ees from a variety of institutions who had been disciplined. The majority feltthat they had been unfairly treated. Most said that work colleagues had beensupportive and shared their sense of injustice. A field study by Fortado (1991)shows some of the ways in which managers exercise discretion in the use of dis-cipline. In particular, he describes ‘the use of the microscope’, whereby man-agers subject an employee to intensive scrutiny to either build a case for theindividual’s dismissal or put pressure on the individual to leave. In the use ofthe microscope managers subvert supportive practices to get rid of a dislikedsubordinate. Some small-scale, qualitative studies of nursing discipline havebeen undertaken in the USA (LaDuke, 2000; Supples, 1993). Both of theseauthors concluded that discipline was often punitive and that there were widevariations in its use.

To summarize, this literature suggests that while a variety of models of dis-cipline exist, a crude model of deterrence often prevails in practice. Effects ofdiscipline are strongly mediated by the way in which it is carried out and itsperceived fairness. Despite studies in the 1980s which attempted to rehabilitatepunishment as a management tool, there is considerable evidence that punitivesanctions produce negative outcomes.


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Studies of the effects of discipline have some methodological limitations.Many psychological studies in this field have depended heavily on experimen-tal studies involving simulation and role play (for example, Fandt et al., 1990).These designs have inherent problems of ecological validity since research sub-jects may be highly motivated to behave in an expected manner under experi-mental conditions (Orne, 1962).

Other studies have used psychometric measurement of attitudes to work-place discipline but there remain difficulties in interpreting the relationshipbetween the attitudes and attributions measured and actual practice (Arvey etal., 1984; Ball et al., 1994; Greer and Labig, 1987). Surveys of actual practicehave been scarce. Knight and Latreille’s (2000) survey suggested a rise in unfairdismissal claims possibly associated with a decline in union density. Very fewqualitative studies of sanctions and punishments in the workplace have takenplace (Fortado, 1991; Rollinson et al., 1997). These studies have greater eco-logical validity but have often been on a small scale and, thus, more field stud-ies of workplace discipline are needed. This article adds to this body ofqualitative literature.

The study: design and methods

The data presented in this article is derived from organizational case studies ofthe management of the ‘problem’ nurse in three healthcare Trusts in the northof England. These Trusts were selected on the basis that they were typical dis-trict general hospitals in suburban areas.

Ethical clearance was obtained for the study in each Trust with the direc-tors of nursing acting as gatekeepers permitting access to nursing staff. Thesample was carefully constructed to protect the identity of individual staff.

The case study sample was constructed by selecting 25 wards across thethree Trusts on the basis of their speciality (see Table 1). In each ward the wardsister and one ward nurse were interviewed.


Table 1 Wards included in the study (shown by clinical directorate and Trust)

Townend TrustMedicine and care of the elderly 4 wardsCare of the elderly mentally ill 2 wardsSpecialist surgery 2 wards

Hilltop Acute Trust Acute Medicine 5 wardsSpecialist surgery 2 wards

Hilltop Community Medicine for the elderly 7 wardsCare of the elderly mentally ill 3 wards

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These 25 wards were managed via seven clinical directorates. All the rele-vant managers at directorate level were interviewed. At Trust level all of thesenior managers, quality managers and personnel managers relating to thestudy wards were also interviewed. All of the target individuals agreed to beinterviewed with the exception of three senior managers in Hilltop Acute Trust.

The numbers of interviews are shown in Table 2.In addition to interviews with nurses and managers, seven union represen-

tatives were interviewed. This included four full-time officers and three branchrepresentatives.

A further sample of 12 directors of nursing in neighbouring Trusts was alsointerviewed. Twelve further key informants were interviewed in relevantnational and regional posts, i.e. regional nurse manager, member of nationalexecutive of trade union. A total of 144 interviews were carried out.

The primary method of data collection was qualitative interviews, lastingone to two hours. The ethics committee required that informants should beoffered the opportunity to refuse the use of a tape recorder owing to the sensi-tivity of the topic. Therefore 53 interviews were tape-recorded and in theremainder, contemporaneous, verbatim notes were taken. To check the accu-racy of the written notes three interviews were simultaneously taped andrecorded in note form. There was good correspondence between notes andtranscripts. A semi-structured interview guide was used (Table 3).


Table 2 Staff interviewed (shown by grade)

Ward sisters/charge nurses 25Staff nurses/ enrolled nurses 25Clinical nurse specialists 7Directorate managers 22Quality assurance and risk managers 6Patients’ representatives 3Personnel managers 10Board level managers 11

Table 3 Topics covered in the interview schedule

Workload/responsibilitiesRelationships between nurses and managersRelationships between colleaguesCommunications and moraleStandards of careAcceptable/unacceptable conductMisconduct/IncompetenceInformal disciplineFormal disciplineImpairment/unfitness

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Other data collected included Trust policies, local press cuttings, observa-tions of Trust meetings and observations of professional conduct cases.

Informants were not chosen on the basis of their involvement in disci-plinary cases but simply as a cross section of staff and managers in the studyTrusts. They were then asked to recall any recent disciplinary cases in whichthey had been involved, whether as a protagonist or bystander. Accounts of76 disciplinary cases were collected and analysed. Most of the accounts givenby nurses were as bystanders to the disciplining of colleagues. A few nurseswho had survived disciplinary action were interviewed. Some disciplinednurses were willing to talk to the researcher but not willing for their story tobe included in the study (these individuals are not included in the formal sam-ple). By definition nurses who had left or been excluded from the organiza-tion as a result of disciplinary action were not included in this study. In thisaccount, therefore, union representatives and colleagues have largely acted asproxies for these individuals and further research needs to take place touncover their experiences.

Multiple accounts of cases were given from different standpoints, e.g.union representative, manager, personnel officer or colleague and it was thuspossible to cross reference and compare several accounts of individual cases.

Thematic and comparative analysis of the data was carried out by handusing colour coding and marginal codes. In addition to comparing individualaccounts of the same incidents given from different standpoints in the organi-zation, the data was constantly compared with official policy discourse on theemerging issues.

Findings

The data presented here describes how disciplinary cases were conducted in theTrusts under study and the models of discipline employed by managers. Nurses’accounts of their perceptions of organizational climate and their relationshipswith managers have been reported elsewhere (Cooke, 2006). Patterns of disci-plinary activity (‘disciplinary waves’) and their relationship to organizationalfactors will be discussed in a separate article. The discussion of findings firstconsiders the quasi-formal discipline which may precede or indeed replace for-mal discipline. This is followed by a description of the formal disciplinary pro-cess following it through from inception to outcome.

Quasi-formal discipline: hidden punishments

Rosenthal (1995) described the existence of quasi-formal discipline in whichelements of formal processes are used without invoking the formal disciplinaryprocedure in full. In this study quasi-formal discipline was an important man-agement tool used mainly to punish staff. There is some limited case study


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evidence of this tactic being used in other organizations (Fortado, 1991).Managers had a range of strategies for dealing with staff that they could not‘get to disciplinary’. Managers explicitly used a range of quasi-formal practicesas straightforward punishments. One frequently given example was movingstaff to another area:

We move staff around the unit a lot. I’ve just moved three care assistants for exam-ple from one ward because of complaints from learner nurses. Nothing you couldreally get to a disciplinary hearing with but vague things about attitudes. So I’vemoved that group of care assistants, split them up onto different wards to work withdifferent staff. Told them exactly why I’ve done it. (Directorate Manager HC35)

Quasi-formal sanctions included moving staff, giving verbal warnings anddisciplinary investigations (sometimes including suspension), which did notlead to a formal hearing. Distribution of quasi-formal cases was as follows:

■ Hilltop Community: 24 cases (outcomes: five resignations; three cases oflong-term sick leave)

■ Hilltop Acute: seven cases (outcomes: four cases of long-term sick leave)■ Townend: three cases (outcomes: two cases of long-term sick leave; one

resignation)

Nurses’ accounts made it clear that in many areas punishments were com-monplace. Allegations that nurses were ‘bullied’ or ‘picked on’ by managerswere made by at least some nurses in five out of the seven directorates. In twodirectorates the majority of ward nurses described a ‘bullying culture’.

According to one staff nurse, management’s role was ‘to punish and noth-ing else’. Punishments were often perceived as arbitrary and inexplicable:

There was an incident when all the G grades (ward sisters) were told we were use-less – none of us were doing what we were supposed to do. They couldn’t say whatwe hadn’t done. We were told we were going to be disciplined. I only wish to thisday I knew what it was all about. (Ward Sister HC 25)

Union representatives suggested that some directorate managers were pre-pared to use the investigative process to punish staff when they knew that therewas insufficient evidence to justify a formal disciplinary hearing. This enabledthem to deliver unofficial verbal and written warnings. A number of accountsfitted this pattern:

There’s a high incidence of disciplinary investigations. Following a debacle at anindustrial tribunal the disciplinary policy is very fair – so fair that managers use theinvestigation, which is outside the policy almost as the procedure. They interviewpeople without them being aware of the purpose; they take statements out of con-text. If it doesn’t go to a disciplinary hearing there is no requirement to allow theperson or their union rep to challenge the evidence. They use the investigation aspunishment without going through the process. There’s a feeling of threat … defi-nitely situations where your face doesn’t fit. People have been witch hunted becausethey haven’t fitted the mould. (Union Representative U6)


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Middle managers may resort to using quasi-formal discipline becausehigher managers have expressed concerns about their frequent use of formaldisciplinary action. Quasi-formal discipline was often invisible to board levelmanagers. For example, in Hilltop Community the Trust board claimed to haveimplemented a ‘blame free’ approach to reporting errors so that the institutioncould learn from its mistakes (DOH, 2000).

In one directorate there were 25 cases of drug errors that led to disciplinaries all ina space of a few weeks. In each case an individual was brought to book. The direc-tor of nursing picked up that fact and ran with it and later disciplinaries were can-celled. (Union Representative U6)

Despite this policy a punitive approach to errors persisted. Drug errors stillautomatically triggered a disciplinary investigation leading to a variety of semi-official sanctions.

To summarize, quasi-formal discipline is often unofficial or semi-officialand may happen out of the gaze of Trust board managers. It is not captured inofficial reports on the incidence of disciplinary cases. Outcomes of quasi-formal discipline were often poor. A substantial number led to long-term sickleave or resignation. Thus quasi-formal discipline empowered middle man-agers with the means to deal with (and sometimes ‘show the drive to’) a prob-lem subordinate, often without the knowledge of Board level managers orhuman resource managers.

Formal discipline: managers’ accounts of the decision todiscipline

I asked managers how the decision to discipline was made. Personnel officersinterviewed said that it was important to ensure that disciplinary action wasappropriate. A few complained of ‘dodgy’ or ‘maverick’ managers who did‘silly things’ and did not contact them until they had ‘got in a mess’. Theypreferred to be involved early on in order to avert inappropriate action intrivial cases:

When we get involved varies a lot with the manager. I’d obviously prefer to but theydon’t always tell you, do they? – whether it’s a good example or not, I’m not sure.We had a lady on one of the wards whose hair did not appear to be an appropriatecolour and it was deemed not particularly acceptable on a ward. They’d asked hercould she do something about the colour and they’d had no success. They didinvolve one of the personnel officers who sat and in the end did get a compromisewhereas it was heading very fast – ‘what’s acceptable to you might not be accept-able to me’, you’re getting into all those sorts of things … but I then got a phonecall from the union rep to say his lady’s in the hairdressers – ‘I’ve got the colourchart in front of me and is colour 69 suitable’ and I said ‘How the hell do I know’.So you get into all those – that was resolved but it could have led to really sillythings … (Personnel Officer HC39)


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Managers displayed widely varying attitudes to formal disciplinary actionduring interviews. Some saw it as a last resort and said the decision to disciplinewas not taken lightly. However, a few managers, perhaps disingenuously, pre-sented the decision to institute a formal disciplinary as a neutral act, somethingwhich they employed merely to ‘get to the bottom of things’.

If there’s an incident, if there is a drug error for example. I want a hearing so I canview the whole because a disciplinary – you haven’t made up your mind what you’regoing to do. It’s an opportunity to explore everything. – So I think we need to takeaway the negative. – I’ve disciplined people and given no penalty. So how people seea disciplinary hearing is difficult. (Directorate Manager HC 35)

For this manager and her colleagues a disciplinary hearing would be theusual response to any untoward incident. Unsurprisingly, therefore, all of theunion representatives interviewed suggested that disciplinary procedures wereoften used unnecessarily. Managers’ motives for disciplinary action were oftenregarded with considerable suspicion by nursing staff. Demotions were a com-mon outcome of disciplinary cases in one Trust and were described as a cost-cutting exercise by some nurses.

There have been some very suspect cases of demotion. One case went to an indus-trial tribunal and was settled out of court … there’s very much a feeling of ratio-nalization of services through the backdoor although I couldn’t prove it. It’sincredibly inappropriate – ‘Let’s downgrade some staff, who can we pick on?’There’s no real logic to it. (Union Representative U6)

The most common reason offered by managers for instituting formal actionagainst a nurse was to protect patients. At present we have few ready answersto questions about the effectiveness of disciplinary action as a risk managementstrategy. Some cases were clear-cut, involving harm to patients, but most caseswere not. Many did not involve patient care at all. Few managers were able toclearly articulate the outcomes that they expected to achieve from disciplinaryaction. Several managers said that the purpose of disciplinary action was toseek an improvement in performance but managers rarely seemed to have giventhought to how disciplinary action would achieve this. There was an assump-tion (often unspoken) that punishment would effect an improvement in perfor-mance. Thus, most managers seemed to operate with a crude and unreflectivemodel of deterrence.

When they were giving reasons for a decision to discipline most managershid behind formal procedures. They said that the individual was in breach ofTrust procedures and they had no choice but to discipline. Nurses often saidthat Trust procedures were in place to allow managers to ‘find someone toblame when things go wrong’.

Management procedures and policies come out six or seven at a time in every manage-ment bulletin. You’re supposed to be aware of every memo for the last six or seven yearsevery minute of the day. If you don’t follow procedure to the letter they’re covered ifanything goes wrong. They don’t allow you to be human. (Staff Nurse HC 72)


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Other common reasons given for commencing formal disciplinary actionwere that the individual showed no remorse or that he or she ‘should haveknown better’ by virtue of seniority. Although managers said that they had nochoice but to discipline, variability in rates of disciplinary cases between man-agers suggested that they exercised considerable discretion. Many managerscited experience as the most important factor informing a decision to discipline.Some managers relied heavily on ‘gut feelings’ and contended that the best wayto make such a decision was to ‘follow your instincts’. Thus, according to onedirectorate manager: ‘Nine times out of 10 the decision is very clear. I just doit’. In contrast those managers who saw formal discipline as a last resort lookedfor evidence that all other avenues to sort the problem out had been exploredand had failed. They were far less likely to resort to disciplinary action thanthose who claimed to follow their instincts.

There was an increasingly defensive culture within Trusts and this hadencouraged the use of disciplinary action, according to many informants. Unionrepresentatives felt that Trusts too often disciplined in order to be seen to bedoing something. This was a growing issue in relation to complaints and fourunion representatives recounted cases when they alleged that Trusts had disci-plined nurses simply to demonstrate to a complainant that their case had beentaken seriously. Several managers acknowledged that they were now working ina particularly pressured climate when dealing with patient complaints:

These days we all err on the side of caution – not just because of legal action,although there is a lot more, but the publicity and how we are seen to react topatients in the light of Bristol, etcetera. We are all keen to be seen to be taking thingsseriously. (Trust Chair)

Union representatives said that some managers were inclined to panicover particular issues such as drug errors or allegations of sexual harassment.This could encourage them to use disciplinary procedures when otherresponses would have been more appropriate. They attributed this to anincreasingly defensive NHS culture and to the fact that these responsibilitieswere now often devolved down to inexperienced managers who were notnurses. Five of the seven union representatives interviewed shared the viewthat managers’ insecurity and inexperience were major factors in the excessiveuse of discipline:

They’re very complaints-conscious nowadays, they act on everything, for exampledrug errors – it varies from Trust to Trust. Some are more enlightened, some justgive the nurse a good rollicking … it’s usually an accident. It’s the good nurses whoget disciplined. The ones who don’t own up to it get away with it more. There is arange of penalties, anything from a written warning to demotion … It’s often inex-perienced managers. They tend to panic. Nurse managers make a difference. Nursemanagement has been decimated in some Trusts. (Union Representative U1)

Training in disciplinary procedures was patchy. Training was in-houseand involved the manager becoming conversant with the Trust’s policies and


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procedures and an introduction to relevant employment law. Some managersmentioned the nurses’ code of conduct (NMC, 2004c) as guiding their deci-sion. The ACAS code of practice (2003) was not mentioned by any of themanagers interviewed. Training was often described as involving anecdotalaccounts from personnel staff and role play. The role play scenarios pre-sented in one Trust during the study employed crude stereotypes of problememployees such as the drunk and the union agitator. Many managers felt thatthey had had little preparation for the responsibility and had had to learn byexperience.

It seems, therefore, that there is great variability in the decision to disci-pline and that managers exercise considerable discretion. Many managersmaking this decision had had little or no preparation and training. This isborne out in differential rates of disciplinary action between Trusts anddirectorates. Although this is a qualitative study and statistical significancecannot be stated, it is worth noting that Hilltop Community Trust producedalmost three times as many accounts of disciplinary action as either of theother two Trusts. This difference reflected differing attitudes among man-agers, with far more managers in Hilltop Community Trust seeing formaldisciplinary action as the normal response to untoward events. Ironically,this Trust had made considerable efforts to profess its support for staff. Ithad won Beacon Status for its staff support strategy yet on the basis of itsdisciplinary record it could justifiably be described as a ‘punishment centredbureaucracy’ (Gouldner, 1954).

The conduct of disciplinary cases

The way in which disciplinary action was carried out could vary enormously. Aminority of managers were aware that the process needed to be managed care-fully in order to ensure the nurses’ continuance in the organization:

I suppose you have to say with a disciplinary ‘What is the outcome you wantto achieve?’ and it’s not about annihilating nurses … so it’s not about ‘I’vemade a mistake, that’s me finished’, we rectify and we learn – we’ve had someexcellent nurses who’ve made some very silly mistakes and they’ll never do itagain … I’d be naïve to think the process didn’t affect them but I think it isaround the support and maybe the counselling after that that goes on.(Directorate Manager HC6)

This manager displays the model of deterrence common to most managersas a justification for disciplinary action: discipline will help nurses to ‘learn’ notto make ‘silly mistakes’. She does, however, show some awareness of the needto support the nurse through the process. Nevertheless, poor outcomes werecommon in this directorate. Treating the accused with respect and avoidingexpressions of hostility and anger have all been associated with positive out-comes (Greer and Labig, 1987). However, disciplinary action was usually


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reported to be a highly negative event. Union representatives often complainedthat disciplinary investigations, in particular, were carried out in a hostile cli-mate. The following account illustrates their concerns:

There was an absolutely horrendous investigation done by very inexperienced peo-ple. They conducted interviews for up to six hours. They didn’t explain what theywere investigating. The people who were interviewed just felt like victims through-out. They weren’t independent. They made comments throughout the interviewsabout what people were saying. They accused people and didn’t accept theiranswers if they weren’t what they were trying to find out. People were not told theyhad a right to a union rep. Some people who were interviewed were too intimidatedto get up and walk out. If they stopped it was assumed they were guilty and hadsomething to hide. Some people broke down in tears sobbing during the interviews.One nurse had been on a night shift and they came in at 6am and kept her to 11am.At the end she was a nervous, gibbering wreck. (Union representative U7)

Procedural justice has also been associated with positive outcomes(Rollinson et al., 1997). Union representatives frequently complained of proce-dural injustices. Most associated this with a defensive culture, produced by thecreation of self-governing Trusts. Prior to the introduction of self-governingTrusts, disciplinary procedures were set nationally by the Whitley Council andwere based on ACAS guidelines. Following the introduction of Trust status,some Trusts substantially rewrote their disciplinary procedures. According toone Union representative this was always a bad sign. Trust status also entailedthe loss of appeal panels at a regional level which were believed to have ensureda degree of consistency and fairness. According to union representatives Trustsnow have a culture of secrecy.

Some managers never learn. Nurses want to be heard if something goes wrong.There needs to be an independent view – you can’t get it in Trusts. Trusts close allthe doors and support the manager. They don’t want to lose face – it has a terrificimpact on all staff. If the Trust admits blame they have to take action against man-agers. In the past if a complaint was upheld you knew managers would be repri-manded – you felt there was justice. There’s been a change with Trusts, there’s noone to go to outside the Trust … managers have no training, no understanding ofnatural justice. They don’t have industrial relations training. Some managers won’tallow trade union reps … In the 1970s administrators were honest, reliable people.Now managers are prepared to lie … This culture of dishonesty has come aboutbecause of Trusts. (Union Representative U3)

The majority of the union representatives interviewed, as well as severalnurses, made the accusation that managers were prepared to lie. Several tradeunion representatives also said that a culture of unfairness was spreading in theNHS as well as a culture of dishonesty. In terms reminiscent of Fortado’s (1991)description of the ‘microscope’, they described managers as collecting trivialmisdemeanours in order to build a case that would stick against a nurse.

Very much staff are treated as guilty, they don’t have their rights explained, they’renot treated in a respectful manner through the process. It’s ‘This is what we think


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and we’ll find the evidence to fit.’ The way staff are handled is not the fairest way… you can get cases based purely on tittle tattle – everybody is asked what theythink and it’s based on subjective tittle tattle – things like disciplining individuals fornot following procedures that haven’t been written. (Union Representative U6)

Thus, all of the union representatives alleged that disciplinary cases werefrequently mismanaged. This may account for the high incidence of negativeoutcomes.

The outcome of disciplinary cases

I have noted that disciplinary outcomes were related to the way in which the dis-ciplinary investigation and hearing were carried out. Disciplinary outcomes led tohigh rates of attrition. I found no clear evidence that disciplinary action effectedan improvement in performance in those who were disciplined (Table 4).

Those union representatives who dealt with other occupational groups saidthat the disciplinary process was particularly stressful for nurses and outcomesworse, leading them to ‘jump ship’. Managers were said to be unnecessarilypunitive when dealing with nurses who felt the stigma of disciplinary actionacutely and were more likely to become isolated from their colleagues:

… of all the staff I deal with the ones that take disciplinary procedures most badlyare nurses. I’ve had nurses suspended and not disciplined and they’ve had to retireon health grounds. Nurses find it particularly difficult. Going through suspensionand investigation, even if there’s no action, nurses exhibit behaviour that says theywill never be the same in that workplace. It’s a more intense reaction than othergroups … They’re told they can’t have contact with people at work. Colleagues willcross the road rather than speak to them. Nurses take the isolation badly. Hotel ser-vices are bound by a code which says that all managers are bastards. Their socialnetworks are maintained when an individual is disciplined. Nurses won’t talk to acolleague who is disciplined in case their own professional practice is called intoquestion. (Union Representative U4)


Table 4 Disciplinary outcomes

Resignation 17Dismissal 12Moved/demoted 9Long term sick leave 9Verbal/written warning 8Exoneration/case dropped 5Retraining 4Suicide 1Unresolved/unknown 11

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Several union representatives identified isolation and lack of supportamong disciplined nurses and associated this with a culture of fear in nursing:

The culture in nursing is ‘Don’t stick your head above the parapet’. If someone is introuble, nurses align with management out of fear. It’s sad what happens. It rein-forces a culture of no natural justice … there’s a fear of disciplinary, fear of gettinginto trouble … Nurses hold their heads pretty low when things go wrong. They goto ground until it blows over. (Union Representative U3)

Many disciplinary cases concerned matters unconnected with patient care.Some happened as a result of adverse incidents that had occurred under situa-tions of stress. However, a few individuals did have persistent problems of con-duct or competence. Several managers reported that when these individualsresigned or were dismissed from the Trust they found employment readily inthe nursing home sector. In only three cases was a complaint to the regulatorybody made.

When managers were able to articulate the outcomes that they hoped toachieve from disciplinary action, they said either that they wanted to achieve animprovement in performance, or, in more serious cases, that they wanted toprotect patients from harm, often by excluding an individual from the work-place. It is questionable whether these disciplinary cases achieved either of theseoutcomes. Where accounts of the effects of disciplinary cases were given, thesewere overwhelmingly negative. Furthermore, when Trusts excluded an individ-ual whom managers regarded as unsafe from the workplace, they often endedup working in the private nursing home sector where they had little supervisionand were dealing with a very vulnerable client group. Thus, it is difficult to seehow the negative outcomes of discipline for nurses can be justified in terms ofpublic protection.

Conclusion

Henry (1987) has suggested four models of discipline likely to exist in the work-place. He also suggested that a plurality of models is likely to exist in any onesetting. In this study it was apparent that although formal procedures could becharacterized as corrective-representative discipline this was by no means theonly model employed. Accounts given by union representatives, but also bymanagers themselves, suggested that punitive authoritarian discipline waswidespread. This model corresponds closely to Gouldner’s description of thepunishment-centred bureaucracy. In this bureaucratic pattern managers striveto exact obedience to rules without considering the causes of infringement and‘with the object of allocating blame and punishment’ (Gouldner, 1954). It is ofparticular interest to note that much punitive discipline occurs during the inves-tigative phase of the disciplinary process and is informal or quasi formal. Thisfrequently renders it invisible in formal accounts of disciplinary activity. Thus,the prevalence of this type of activity is largely unknown.


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When managers’ own accounts of the decision to discipline were elicited,the deterrence model, which views discipline as consisting of the ‘crude use ofpsychological conditioning’ (Rollinson et al., 1997), was the most prevalentexplanation for their actions. Many managers continued to rely on instinct inmaking the decision to discipline. Their instincts appeared to be punitive.Punishment was rationalized as having a corrective effect, although there wasno good evidence to support this assumption.

Complaints about the conduct of disciplinary cases by union representa-tives and nurses were frequent. These were often framed in terms of negativedescriptions of organizational culture. Union representatives described Trusts ashaving a culture of fear, a culture of unfairness, a defensive culture, a culture ofdishonesty and a culture of secrecy. Nurses corroborated these pejorativeaccounts and also frequently described their workplaces in terms of a culture ofbullying. This is corroborated by some recent trade union surveys (Ball et al.,2002). Many informants believed that the creation of self-governing Trusts hadconsiderably worsened the handling of disciplinary cases. Trust status wasbelieved to have had a negative impact on organizational culture, makinghealthcare organizations more closed and defensive. Trust status also gave Trustmanagers greater independence in their conduct of disciplinary cases and deniedemployees access to an independent appeals procedure.

Previous studies of the effects of discipline have found that the expressionof negative affect has had a detrimental impact on outcomes (Greer andLabig, 1987; Rollinson et al., 1997). In common with these studies, this studyfound that disciplinary activity took place in an atmosphere of hostility andthreat that belied the apparent objectivity and neutrality of the formal pro-cesses. Thus disciplinary activity led to unnecessarily high levels of attrition,which, according to one union representative, was ‘surprising when they’reshort of nurses’.

Trevino (1992) has highlighted the negative impacts of inconsistency andinjustice in the disciplinary process. Disciplinary injustice does not just drive theindividuals who have been disciplined out of the organization. Both Trevino(1992) and Rollinson et al. (1997) point to bystander effects in which a widersense of perceived injustice lowers morale, increases rates of attrition and has adetrimental impact on performance. This study confirmed these previous find-ings. In areas of high disciplinary activity, nurses were fearful, distrustful andacutely aware of the apparently arbitrary nature of much disciplinary activity.Morale was low and many nurses were planning to leave the organization.

We can link these negative effects back to the models of discipline whichmanagers employed. Inconsistency, unfairness and a hostile climate were aseemingly inevitable consequence of managers’ use of a punitive authoritarianapproach to discipline. Their confidence in their ability to make objective judge-ments, which were guided only by instinct and gut feelings, made negative out-comes of discipline unavoidable.


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Acknowledgements

This study was funded by the UKCC. I am grateful to Huw Beynon for his supervi-sion and support.

References

ACAS (Advisory, Conciliation and Arbitration Service) (2003) Disciplinary andGrievance Procedures: Code of Practice 1. London: ACAS.

Ackroyd, S. and Thompson, P. (1999) Organisational Misbehaviour. London: Sage.Arvey, R., Davis, G. and Nelson, S. (1984) ‘Use of Discipline in an Organisation’,

Journal of Applied Psychology 69(3): 448–60.Arvey, R. and Ivancevich, J. (1980) ‘Punishment in Organisations: A Review,

Propositions and Research Suggestions’, Academy of Management Review 5:123–32.

Ball, G., Trevino, L. and Sims, H. (1994) ‘Just and Unjust Punishment: Influence onSubordinate Performance and Citizenship’, Academy of Management Journal37(2): 299–322.

Ball, J. et al. (2002) Working Well? London: Royal College of Nursing.Baron, R. (1988) ‘Negative Effects of Destructive Discipline: Impact on Conflict,

Self-efficacy and Task Performance’, Journal of Applied Psychology 73(2):199–207.

Carvel, J. (2004) ‘NHS Trust Reinstates Crouton Surgeon’, The Guardian, 25March.

Clothier, C. (1994) The Allitt Inquiry. London: HMSO.Cooke, H. (2006) ‘Seagull Management and the Control of Nursing Work’, Work,

Employment and Society 20(2): 223–43.DoH (Department of Health) (2000) An Organisation with a Memory. London:

DoH.DoH (Department of Health) (2001) Establishing the New Nursing and Midwifery

Council. London: DoH.DoH (Department of Health) (2003) Maintaining High Professional Standards in

the Modern NHS. London: DoH.Edwards, P. and Whitston, C. (1994) ‘Disciplinary Practice: A Study of Railways in

Britain’, Work, Employment and Society 8(3): 317–37.Fagan, J. (2004) Suspension Failure in the NHS. Tamworth: Suspended Nurses

Group.Fandt, P., Labig, C. and Urich, A. (1990) ‘Evidence and the Liking Bias: Effects on

Managers’ Disciplinary Actions’, Employee Responsibilities and Rights 34:245–65.

Fenley, A. (1998) ‘Models, Styles and Metaphors: Understanding the Managementof Discipline’, Employee Relations 20(4): 349–60.

Fortado, B. (1991) ‘Exercising Managerial Prerogatives: The Findings of Four FieldStudies’, City and Society 5(1): 76–96.

Fortado, B. (1992) ‘The Accumulation of Grievance Conflict’, Journal ofManagement Inquiry 1(4): 288–303.


069809 Cooke 15/11/06 9:15 am Page 705

Foucault, M. (1977) Discipline and Punish. The Birth of the Prison. London: AllenLane.

Gouldner, A. (1954) Patterns of Industrial Bureaucracy. New York: Free Press.Greer, C. and Labig, C. (1987) ‘Employee Reactions to Disciplinary Action’, Human

Relations 40(8): 507–24.Henry, S. (1987) ‘Disciplinary Pluralism: Four Models of Private Justice in the

Workplace’, Sociological Review 35: 275–319.Kennedy, I. (2001) Learning from Bristol. London: HMSO.Knight, K. and Latreille, P. (2000) ‘Discipline, Dismissals and Complaints to

Employment Tribunals’, British Journal of Industrial Relations 38(4): 533–55.LaDuke, S. (2000) ‘The Effects of Professional Discipline on Nurses’, American

Journal of Nursing 1000(6): 26–33.Miller, P. and Rose, N. (1990) ‘Governing Economic Life’, Economy and Society

19(1): 1–29.NAO (National Audit Office) (2003) The Management of Suspensions of Clinical

Staff in NHS Hospital and Ambulance Trusts in England. London: HMSO.NMC (Nursing and Midwifery Council) (2004a) Fitness to Practice Annual Report

2003–4. London: NMC.NMC (Nursing and Midwifery Council) (2004b) Fitness to Practice Annual Report

2004–5. London: NMC.NMC (Nursing and Midwifery Council) (2004c) The NMC Code of Professional

Conduct. London: NMC.Orne, M. (1962) ‘On the Social Psychology of the Psychological Experiment with

Particular Reference to Demand Characteristics and their Implications’,American Psychologist 17: 776–83.

Public Accounts Committee (1995) The Suspension of Dr O’Connell, HC 322,Session 1994–95. London: HMSO.

Public Accounts Committee (2004) The Management of Suspensions of ClinicalStaff in NHS Hospitals and Ambulance Trusts in England, HC 296, Session2003–04. London: HMSO.

Pyne, R. (1998) Professional Discipline in Nursing, Midwifery and Health Visiting.Oxford: Blackwell.

Rollinson, D., Handley, J. and Hook, C. (1997) ‘The Disciplinary Experience andits Effects on Behaviour’, Work, Employment and Society 11(2): 283–311.

Rosenthal, M. (1995) The Incompetent Doctor: Behind Closed Doors.Buckingham: Open University Press.

Sims, H. (1980) ‘Further Thoughts on Punishment in Organisations’, Academy ofManagement Review 5(1): 133–8.

Supples, J. (1993) ‘Self Regulation in the Nursing Profession’, Nursing Outlook41(1): 20–4.

Tomlin, P. (2004) ‘An Occupational Health Problem’, Lecture to the Scottish Societyof Occupational Health Doctors, Glasgow, March.

Trevino, L. (1992) ‘The Social Effects of Punishment in Organisations’, Academy ofManagement Review 17(4): 647–76.


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Hannah Cooke

Hannah Cooke is a lecturer in the School of Nursing Midwifery and Social Work at

the University of Manchester. Her research interests include nursing conduct and com-

petence as well as nurses’ working conditions and working lives.

Address: School of Nursing Midwifery and Social Work, University of Manchester,

Coupland 3 Building, Coupland St, Manchester M13 9PL, UK.

E-mail: [email protected]

Date submitted June 2005Date accepted July 2006


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Examining the disciplinary process in nursing: a case study approach

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