Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review

Aunger, Justin A.; Abrams, Ruth; Westbrook, Johanna I.; Wright, Judy M.; Pearson, Mark; Jones, Aled; Mannion, Russell; Maben, Jill

Abstract

Background: Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted – but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim: To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources: Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results: Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions: Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations.

Citation

Aunger, J. A., Abrams, R., Westbrook, J. I., Wright, J. M., Pearson, M., Jones, A., Mannion, R., & Maben, J. (2024). Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review. Health and Social Care Delivery Research, 12(25), https://doi.org/10.3310/PAMV3758

• Journal Article Type: Article
• Acceptance Date: Nov 7, 2024
• Online Publication Date: Aug 1, 2024
• Publication Date: Aug 1, 2024
• Deposit Date: Dec 23, 2024
• Publicly Available Date: Jan 3, 2025
• Journal: Health and Social Care Delivery Research
• Print ISSN: 2755-0060
• Electronic ISSN: 2755-0079
• Publisher: NIHR Journals Library
• Peer Reviewed: Peer Reviewed
• Volume: 12
• Issue: 25
• DOI: https://doi.org/10.3310/PAMV3758
• Public URL: https://hull-repository.worktribe.com/output/4963540