Afshin Alijani
Consultant Surgeon
Dundee
Scotland
Healthcare professionals frequently find themselves as bystanders. In the course of clinical work, we may witness poor practice, inappropriate behaviour or departures from accepted standards. Becoming a bystander is rarely a matter of choice. It can happen unexpectedly, often in circumstances where the significance of what has occurred is uncertain and where subsequent action may carry personal or professional consequences.
A bystander is someone who becomes aware of an event or behaviour involving others without being directly involved. The challenge lies not simply in witnessing what has happened, but in deciding what it means and whether action is required. Effective bystanding therefore depends on attention, judgement and, where appropriate, intervention.
Some events are easy to recognise. Shouting, overtly unsafe behaviour or a clear breach of procedure readily attract attention. Other problems are much less visible. Exclusion, innuendo, repeated minor behaviours, omissions and system failures may be noticed only gradually. An observer may witness only a single apparently minor event, while the person affected may be experiencing the latest episode in a much wider pattern. Repetition can indicate a persistent problem; several small events can have a significant cumulative effect; and one apparently insignificant event may contribute to a later cascade of consequences. The difficulty is therefore not simply noticing an event, but recognising its significance.
Furthermore, there are several barriers between recognising a concern and taking action.
The first is ambiguity. The observer may have incomplete information, be uncertain about intent, or be unsure whether harm has occurred. The behaviour may have been deliberate, careless, humorous, accidental or misunderstood. The history or relationship between those involved may be unknown. If other people appear unconcerned, or if the person affected does not object, the observer may question their own interpretation.
The second is normalisation. Behaviour that occurs repeatedly without challenge can gradually become accepted, and new members of the team learn the established behaviours of those around them. Normalisation is particularly common in organisations under sustained operational pressure, where problematic behaviours may be tolerated because other issues seem more urgent. What was once exceptional can quietly become routine.
The third is diffusion of responsibility. When several people are aware of a problem, each may assume that someone else will act. Hierarchy can amplify this. Junior staff may believe that senior staff should intervene; senior staff may believe that those more directly involved should do so. The result is collective awareness without individual ownership.
A fourth barrier is personal and professional risk. Speaking up may be perceived to threaten relationships, reputation or career progression. These concerns are particularly important where there is a significant power imbalance. Previous examples of adverse consequences for those who have spoken up can strongly reinforce this reluctance.
A fifth barrier is uncertainty about how to act. A person may recognise a problem and wish to respond but not know how. Reporting mechanisms may be unclear, confidentiality uncertain and the appropriate degree of escalation difficult to judge. Individuals may not know whether to challenge behaviour immediately, speak privately, seek advice or make a formal report.
Finally, there is futility. Previous concerns may have been ignored, organisational processes may have been slow or opaque, and wrongdoing may appear to have carried no consequences. Staff may conclude that the organisation either does not know how to respond, cannot act, or has chosen not to act. When this happens, the question becomes not whether action is justified, but whether it will make any difference.
These barriers help explain why recognising a concern does not automatically lead to action. They also point to responsibilities on both sides: the witness must decide when and how to raise a concern, while the organisation must make it possible to do so safely and meaningfully.
For the witness, the task is not to establish guilt, but to remain attentive, exercise judgement and distinguish observation from interpretation. Concerns should be raised sufficiently early when something may require further attention, while avoiding assumptions about motive. There is an important distinction between raising a concern and making an accusation.
The organisation has an equally important responsibility. If staff are expected to raise concerns, organisations must ensure that doing so is safe, worthwhile and followed by a fair process. Reporting should be straightforward and accessible. Those raising concerns in good faith should be protected from retaliation, while the rights and reputation of the person about whom the concern has been raised must also be respected.
A concern should trigger assessment, not an automatic punitive response. Early reporting should initially carry as little consequence as reasonably possible for either party. Immediate restrictions may sometimes be necessary where there is a credible risk to patients, staff, witnesses or the integrity of an investigation, but prolonged exclusion should not become the default response simply because an allegation has been made.
The organisation’s first question should be: what immediate measures, if any, are proportionate to the actual risk while the facts are established?
The subsequent process should be prompt and transparent: rapid assessment, timely feedback and proportionate action.
Organisations must also be alert to the risk of overcorrection. Previous high-profile failures or intense public scrutiny can understandably make organisations risk-averse. The danger is that concern about repeating past mistakes can produce defensive decision-making, where reputational anxiety begins to outweigh the facts of the individual case. Previous failures should strengthen vigilance and improve process, but should not displace fairness, proportionality or evidence-based judgement.
There is also an important counterbalance. Encouraging staff to raise concerns must not create a culture in which every unusual interaction is regarded with suspicion. Not every mistake is misconduct, not every disagreement is bullying and not every awkward interaction requires formal escalation.
The aim should therefore be to lower the threshold for appropriate enquiry, not for judgement or condemnation. A concern may reasonably be raised while uncertainty remains; conclusions and significant consequences should require a higher evidential threshold.
Training is central to achieving this balance. Expecting staff to speak up without teaching them how creates an obligation without providing the necessary skills. Organisations should train staff not simply to speak up, but to become thoughtful and proportionate bystanders. Training should help staff recognise concerning behaviour, distinguish observation from interpretation, exercise judgement in ambiguous situations and understand how and when to escalate. Realistic scenario-based training is particularly valuable because it develops judgement rather than teaching only rules. Active bystander programmes have already been introduced in several UK medical schools, including Edinburgh, Oxford, Glasgow, Liverpool and Norwich, and similar approaches could be adapted more widely for clinical teams. Such training lends itself well to inclusion as part of the induction for new members of clinical teams.
Those receiving concerns also require training. Staff will quickly lose confidence in speaking up if concerns are ignored, handled poorly, followed by prolonged silence or met with disproportionate action.
Effective bystanding therefore depends on the knowledge, skills and judgement of the witness, as well as the quality of the organisational response.The aim should be neither a culture of silence nor one of premature or disproportionate response, but one in which staff notice early, judge carefully and escalate appropriately, supported by organisations that listen calmly, assess rapidly and act proportionately.
