Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review

Abstract

Background Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom. Methods This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. Results Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics. Conclusions Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups. 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

“…Our results highlight that strategies to improve safe co-worker communication should include a focus on behaviours such as withholding information and ignoring opinions and their contributions to increased safety risks to patients. This evidence is much needed to inform more effective intervention programmes [ 28 ].…”

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

“…This study is part of a larger realist review which also considers interven�ons that atempt to reduce, mi�gate, and prevent UB [3,35]. Our analysis of the contributors to UB suggests that contributors can be circumstances that 'naturally' exist in an organisa�on (e.g., hierarchies, workload, etc).…”

“…As such, it is likely to be more produc�ve for organisa�ons to focus on modifiable factors, targetable by interven�ons, to reduce UB. Such interven�ons could include a focus on improving working condi�ons, improving climate and culture, fostering processes to speak up and be heard, and elimina�ng barriers to providing high quality care [3,35]. In this manner, an organisa�on can create an environment that is intolerant of UB, regardless of the individual staff working at their organisa�on.…”

“…By drawing on a realist review methodology, we aimed to build an understanding of how and why various contributors lead to UB, how these contributors interact, and how UB leads to nega�ve impacts on pa�ents and staff. We intended for these findings to enable the design of beter interven�ons to target contributors to UB in healthcare workplaces [35].…”

The future of the NHS depends on its workforce

“…Less than two thirds of staff (62.3%) feel safe to speak up about anything that concerns them, and only half (50%) are confident that their organisation would deal with their concern 4. Interventions are now becoming available to tackle unprofessional39 or transgressive behaviours,40 and priority should be given to their implementation and evaluation.…”