Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review

Abstract

Background Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB. Methods A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. Results We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust. Conclusion Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB. Study registration This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490.

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals

“…However, the relationship between these and unprofessional behaviour has rarely been examined. How unprofessional behaviour can be an antecedent to increased risks to patient safety were exemplified in the accounts provided by staff, particularly how such behaviour can undermine psychological safety [24] . Analyses of the reports also identified a number of situational factors and organizational characteristics beyond individual factors (e.g.…”

“…personality) that may increase the propensity to engage in unprofessional behaviour, including high workload, time pressures, inadequate coordination, teamwork, supervision and leadership, and organizational constraints (e.g. lack of equipment or resources) [ 24 , 25 ]. These potentially error-producing factors should be targets of organization-wide improvement strategies, along with focussing on efforts to change individual behaviour [ 26 , 27 ].…”

“…These potentially error-producing factors should be targets of organization-wide improvement strategies, along with focussing on efforts to change individual behaviour [ 26 , 27 ]. A further illustration of the multifaceted drivers of unprofessional behaviour which interact in complex ways has been demonstrated in a recent realist review [ 24 ].…”

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals

“…Training senior staff as messengers and providing them with the skills to address unprofessional behaviour, as well as rewarding staff for positive behaviour are all strategies which are incorporated into the Ethos program, but there will be local variation in the extent to which these strategies are effective and sustained. As a recent realist review [ 9 ] has identified, the problem of unprofessional behaviour needs to be tackled in a holistic way recognising a multitude of factors in different contexts.…”

“…Unprofessional behaviour in healthcare is widespread [ 1 – 3 ] and significantly undermines the effective functioning of teams, staff wellbeing, patient experience and safety, and negatively impacts organisational productivity and costs [ 3 – 8 ]. Unprofessional behaviour encompasses a spectrum, from overtly hostile, bullying and inappropriate behaviours such as physical and verbal abuse, to more subtle behaviours such as passive aggression, rudeness and incivility [ 3 , 9 ]. Consistently high rates of incivility and bullying between healthcare co-workers have been demonstrated in surveys from multiple countries and settings [ 2 , 10 – 12 ].…”