Reducing Misogyny, Improving Sexual Safety and Establishing a ‘New Normal’

Bron Biddle, Programme Lead, Reducing Misogyny and Improving Sexual Safety, Association of Ambulance Chief Executives (AACE)

In an evolving landscape of increased societal awareness, cultural reviews and legislative changes, the narrative of sexual safety has shifted. Employers are now expected, both legally and ethically, to demonstrate a preventative approach to workplace sexual misconduct.

Evidence shows that sexual harassment has long-lasting mental and physical effects on individuals. The organisational impact includes increased absence, lower job satisfaction, career interruption, high turnover, low psychological safety, lower diversity and ‘word of mouth’ reputational damage.

Over time, misogynistic behaviour and harassment at work can become normalised, risking cultural stagnation, harmful power imbalances and silencing. It is important that organisations take proactive steps to ensure a safe and inclusive working environment for all.

Here, I will look at some of the positive work done to reduce misogyny and improve sexual safety, as well as the background to why it is so sorely needed.

Background

In 2023, the Women and Equalities Committee put out a parliamentary call for evidence. The Association of Ambulance Chief Executives (AACE) and the Ambulance Service Charity (ASC) submitted written evidence and were later called to present on the question, ‘To what extent is there evidence that escalating behaviours is a particular problem within the emergency services and other public sector organisations?’

The answer runs deep into workplace culture.

According to a 2018 study on bullying and harassment amongst First Responders in the US, specific factors such as ways of working, hierarchies and workforces being historically male-dominated seem to contribute to issues with workplace culture and attitudes.

The NHS Staff Survey released in 2023 saw the inclusion of new questions relating to sexualised behaviours. Out of the 675,140 NHS colleagues who responded, the results revealed that roughly 84,000 had faced sexual assaults and harassment by the public and other colleagues (12%).

Approximately 1 in 12 (58,534) said they had experienced at least one incident of unwanted sexual behaviour from patients, patients’ relatives and other members of the public. Almost 26,000 (3.8%) also reported unwanted sexual behaviour from colleagues.

Rates were highest in the ambulance workforce, with more than 27% reporting sexual harassment from the public and just over 9% reporting sexual harassment from colleagues. This makes the ambulance service a concerning outlier when compared to other areas of healthcare.

Evidence from other sources has also been increasing. A joint investigation by the British Medical Journal (BMJ) and the Guardian found that more than 35,000 sexual safety incidents were reported to 212 NHS trusts in England between 2017 and 2022. Similar concerns were indicated by the National Guardian’s Office’s Speak up review of ambulance trusts and reports from bodies like the CQC (see their 2020 report into the East of England Ambulance Trust).

Meanwhile, media attention also began to increase (see Sky News’s piece ‘I was given a choice of bosses to sleep with: Life as a female paramedic’) and work by activist organisations like Surviving in Scrubs, which calls for sexual misconduct in healthcare to be taken seriously, was becoming more prominent.

Turning the tide: first steps

In September 2023, following increased activism and evidence surfacing, the first NHS England Sexual Safety Charter was established. This brought together key partners across the healthcare system who committed to ten core principles and actions, with the aim of creating a zero-tolerance approach to unwanted, inappropriate and/or harmful sexual behaviours in the workplace. Every ambulance service in England signed the charter, along with a broad range of other healthcare organisations.

In October 2023, England’s Chief Allied Health Professions Officer launched the national ambulance programme, 'Reducing Misogyny & Improving Sexual Safey in the Ambulance Service', which all ambulance services committed to.

Also in 2023, ambulance sector stakeholders representing all four UK nations came together to form a national consensus group. This group developed an evidence base and action plan, including evidence-based recommendations for reducing misogyny.

Tasked with supporting each ambulance service to implement the recommendations, the Association of Ambulance Chief Executives (AACE) began working to align approaches and create a long-term foundation for the improvement of sexual safety.

Work done by AACE

AACE observed that, when the starting point for change is acceptance of the problem, a ‘new normal’ can be established and the culture of tolerance in a workplace can become less dominant.

• To bring together expertise across the sector, AACE set up the National Ambulance Sexual Safety Community of Practice, which provides space for best practice to be shared and connect members to lived experience. Made up of colleagues in related roles such as HR, Safeguarding, Freedom to Speak Up and Violence and Prevention, the community of practice promotes learning, the development of dialectical thinking skills, broader understanding of wider issues and provision of peer support.
  
  
• Concerns related to sexual safety can often lead to high-stress high-conflict investigations. Recognising this, AACE established the sector’s first ‘people professional development programme’. The programme aims to improve the capability and confidence of colleagues responsible for advising on sexual safety-related concerns at work – colleagues who are essential for creating change. Through a series of learning events facilitated by subject matter experts, participants examine into sexual safety from different angles like employment law, regulation, safeguarding, professional boundaries, online polarisation and AI.
  
  
• When asking these participants about current barriers to the improvement of sexual safety, AACE found that fear of speaking up, lack of trust in processes, perceptions of ‘banter’ and a lack of investigative expertise were the most common. This response is representative of ambulance services throughout England.
  
  
• As a result, AACE focused further efforts on ways to empower colleagues to navigate these incidents, and establishing supportive infrastructures and trustworthy systems to help them.
  
  
• To ensure top-down learning, AACE has committed to delivering a learning session to every ambulance service board in the UK (consisting of the service’s Chair, CEO, executive management and non-executive management). The session focuses on improving the board’s understanding of the ‘external landscape’ of how sexual safety interfaces with the ambulance sector. This might include legislative changes, changes to NHS England’s fit and proper persons test framework, parliamentary evidence gathering and culture reports.
  
  
• It also focuses on providing updates from the AACE’s national 'Reducing Misogyny' approach and sets out expectations of each board, like viewing sexual safety as a risk requiring continual oversight and taking collective ownership of it.
  
  
• Following the sessions, some senior leaders have elected to take part in reverse mentoring. This exercise can break down internal hierarchies, improve understanding of intersectionality, and allow participants to appreciate the whole-life impacts caused by an experience of sexual misconduct, discrimination or oppression.
  
  
• AACE also established a student paramedic advisory panel to ensure the student perspective and voice is represented. Students have been identified by The College of Paramedics as a vulnerable group who are likely to be exposed to themes of abuse of power.
  
  

Measuring progress

Running parallel with the delivery of this work are progress checks, which are undertaken with each ambulance service to assess the impact of its sexual safety improvement efforts.

A key message that AACE gives boards is ‘Don’t fall in love with your action plan’: a reminder to be agile in responding to external factors and, most importantly, to keep listening to the voices of those affected and learning from them.

Overcoming resistance

One unexpected hurdle for AACE has been organisational resistance at varying levels.

There can be defensiveness, denial of the problem, fear of vexatious allegations, a perception that ‘banter’ will be outlawed, or an expectation that another issue will be raised and derail the conversation.

Overcoming organisational resistance can only be achieved through a multifaceted approach. But AACE believes it is important to allow it to surface: only then can it be addressed by creating an appropriate conversational space. In keeping with this, AACE developed a resistance guide to support colleagues leading on this work.

Work done by other organisations

The Welsh Ambulance Service (WAST) established their ‘Voices Staff Network’ to reset cultural norms. The network aims to be a safe space in which colleagues can feel empowered to improve their understanding of a broad range of topics including intersectionality, men’s mental health, loneliness and online polarisation.

To surface concerns and improve psychological safety, WAST also introduced measures such as an anonymous reporting platform and employment of dedicated investigating officers. The subsequent increase in reported concerns – which is significant – shows the increase of trust following this.

Similarly, at the London Ambulance Service, Chief People Office Damian McGuinness has described a ‘critical cultural swing’ following the launch of their sexual safety charter in 2022. Regarding people’s perceptions of whether sexual safety concerns will be addressed, he describes the shift from a hope that they ‘might’ be, to an expectation that they will.

Other examples of proactive approaches include:

• The North West Ambulance Service, which has been visiting colleagues as part of their campaign ‘Stop Speak Support’
• The South Central Ambulance Service, which has implemented a ‘speakupbulance’ that Freedom to Speak Up Guardians use to support colleagues
• The East of England Ambulance Service, which is embedding sexual safety learning content within its leadership development programme and promoting healthy team cultures through a variety of engagement initiatives
• The South Western Ambulance Service, which has transformed its disciplinary investigation process, including the introduction of an impact statement to assist panel deliberations.

Lucy Manning, Assistant Director for People Operations at the South Western Ambulance Service, explains that this trauma-informed approach has proven invaluable: ‘it provides the chairperson with a deeper understanding, from all perspectives, in these complex and multi-factorial cases. We believe it is essential for the person who was brave enough to speak up to share with the panel how the process has felt for them, and most importantly, how they would feel should they come into contact again with the person they raised a concern about. This has become an essential part of deliberations and has enabled disciplinary panels to make proportionate decisions.’

Learnings from other sectors

Beyond healthcare, the ambulance sector is connected to other blue light services that provide opportunities to consider which cultural factors may be contributing to systemic problems. Learnings can be taken from organisations such as the Metropolitan Police and the findings of the 2023 Baroness Casey report.

It is clear that being alert to sexual misconduct and taking ownership of it can be the catalyst for change in other organisations. However, these comparisons also highlight the long-term nature of cultural transformation – a point supported by the recommendations within NHS England’s culture review of ambulance trusts.

Conclusion

Given the growing evidence base and the work done in the sector so far, we can conclude that, although good foundations have been laid, there is more to do.

To create a zero-tolerance environment in any workplace, a number of things need to happen, which I will summarise briefly here.

• Education is needed.
• Speaking up must be normalised.
• In order to find answers, questions must be asked.
• Outside your organisation, the external landscape must be studied so that your eyes stay open.
• Within it, colleagues must be helped and supported to establish clear professional boundaries.
• Most importantly, trust must be built with those affected, through continued and visible commitment to this work.

‘New normals’ are being created across the country. There remains significant work to do, but as teams and organisations acknowledge the problem, they make meaningful change possible.