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 .

Keywords: Acute health care; Bullying; Incivility; Organisational culture; Patient safety; Professionalism; Psychological safety; Psychological wellbeing; Unprofessional behaviour; Workforce.

Fig. 1

Example coding structure for contributors to UB in Step 4

Fig. 2

Flow diagram for realist review process. Updated from Maben et al. (2023) [43]

Fig. 3

PRISMA style diagram reflecting the document selection process

Fig. 4

Overarching, high-level programme theory

Fig. 5

The process of workplace disempowerment (mechanisms 1 to 6). Italicised mechanisms are those that can directly increase incidence of UB. Boxed items are individual contributors

Fig. 6

Programme theory for how harmful work processes and cultures work (mechanisms 7 to 13). Italicised mechanisms are those that can directly increase incidence of UB

Fig. 7

Programme theory for how inhibition of social cohesion works (mechanisms 14 to 19). Italicised mechanisms are those that can directly increase incidence of UB

Fig. 8

Programme theory for how reduced ability to speak up and lack of manager awareness and urgency work (mechanisms 20 to 23)

Fig. 9

Programme theory depicting interactions of contributors and the mechanisms they trigger. Arrows depict interactions and vicious cycles between mechanisms (double ended arrows)

Fig. 10

Programme theory for how UB leads to reduced care quality and safety. Previously presented CMOCs are numbered in the diagram. Intended to be read from left to right