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

Unprofessional behaviours (UB) can be defined as “any interpersonal behaviour by staff that causes distress or harm to other staff in the healthcare workplace” (Aunger J, Abrams R, Westbrook J, Wright J, Pearson M, Jones A, et al:  Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review, forthcoming). These encompass a range of actions such as incivility, microaggressions, harassment and bullying. Such behaviours persist within healthcare systems globally [1, 2]. Rates differ significantly between countries and contexts; e.g. data from Australia across seven hospitals showed 38.8% of 5178 staff respondents reported experiencing UB on a frequent (weekly or more) basis during the past year, with 14.5% experiencing extreme events such as physical assault [1]. Similarly, in a hospital in Portugal, prevalence of bullying has been found to be 8% [3], and, in Italy, prevalence has been found to be 12.3% for males but 16.4% for females [4]. There are numerous recent scandals in the United Kingdom’s (UK) National Health Service (NHS) that further demonstrate its prevalence. For instance, a 2023 investigation into clinical safety at University Hospitals Birmingham NHS Foundation Trust revealed a pervasive culture of “bullying and toxicity” which had adverse effects on patient care [5]. Similar problems were observed at the East of England Ambulance Service Trust from 2020–2021, which faced monitoring by the Equality and Human Rights Commission due to widespread sexual harassment and abuse [6]. UB has been described as an unaddressed crisis in healthcare (Aunger JA, Abrams R, Westbrook J, Mannion R, Jones A, Pearson M, et al: Unprofessional behaviour between acute healthcare staff: an unaddressed UK crisis, submitted) [7], and one which requires urgent action and further research [2].

Patient care is being jeopardized and staff psychological wellbeing negatively affected by the widespread occurrence of UB [2]. UB in acute healthcare settings can impair communication and concentration, reduce trust in teams, cause a loss of confidence in work ability for staff, and reduce psychological safety [8]. All these factors can lessen the sharing of important patient information, allowing medical errors to go unchallenged and reducing patient safety [9‐11]. Illustrating this, a comprehensive retrospective cohort study conducted in the USA examined the data of 200 surgeons and 13,653 of their patients [12]. Results revealed that patients whose surgeons had a greater number of co-worker reports for UB had a significantly increased risk of experiencing surgical and medical complications. Patients whose surgeons had received 1–3 reports of UB within the 36 months preceding the operation faced a 14.3% higher risk of complications, while those whose surgeons had accumulated 4 or more reports faced an 11.9% higher risk [12]. Similar results have been reported when incivility scenarios are simulated [10].

UB between healthcare staff can also negatively impact staff psychological wellbeing [12, 13]. For those who are targeted by or who witness UB, it can result in alienation, depression, and, in severe cases, even suicidal thoughts [14]. This loss of wellbeing can lead staff to take sick leave or leave the organisation or profession entirely [13]. Indeed, bullying and harassment have been cited as one of the primary reasons for the current workforce crisis, with a recent report suggesting 49% of healthcare staff who have experienced UB are seeking another job outside of their organisations or healthcare as soon as possible [15, 16].

Such staff turnover can have significant economic implications [13]. A cautious estimate suggests that the cost of UB to the UK’s NHS amounted to approximately £2.28 billion per year when considering factors such as sickness absence, employee turnover, reduced productivity, compensation and litigation costs. This is equivalent to 1.52% of the NHS’ budget for 2019/2020 [13]. In the USA, replacing staff due to UB, can, for example, cost between $22,000 and $64,000 per nurse [17]; similarly, an estimate of the combined costs for disruptive physician behaviours (e.g. due to turnover, medical and procedural errors) in a 400-bed hospital was found to exceed $1 million.

Prevalence of reported UB varies across different staff members and groups. Data from the UK NHS Workforce Race Equality Standard in 2022 shows that a higher percentage of black, minority, and ethnic (BME) respondents experienced UB compared to their white counterparts, particularly when it originated from managers [18]. Staff members with long-term health conditions or illnesses were also more affected by UB from co-workers [18, 19] and a systematic review including studies looking at prevalence of UB between healthcare staff suggests that more studies find that women are more frequently targets than males [20]. Despite increased attention towards addressing misogyny, racism, and discrimination through social movements like #MeToo and #BlackLivesMatter, there has been little improvement in the experiences of NHS staff between 2018 and 2022. Indeed, discrimination, as reported in the NHS Staff Survey, has been identified as the primary reason for staff leaving NHS hospitals, and thereby contributing to the ongoing NHS workforce crisis [21].

There have been previous attempts to address widespread UB. Several studies have sought to collate and understand interventions to reduce UB in [22] and outside of healthcare [23]. However, existing reviews have focused on only one particular type of UB, such as bullying [22], and their applicability to acute healthcare settings may be limited [24]. Interventions have been implemented in a range of contexts using many different types of approach [22, 25, 26]. Additionally, interventions and the behaviour change strategies they use are often poorly described with insufficient explanation of how and why they are intended to work (see Table 3 below) [26]. Therefore, in this article, we draw on realist methodology to open the ‘black box’ of a heterogenous group of interventions, implemented in complex healthcare systems. In doing so, we synthesise evidence on how interventions to address UB between staff in acute care may work, why and whom they benefit.

Our review set out to investigate how and why interventions to address UB between staff in acute care work, and whom they benefit. We found that overall, interventions to reduce, mitigate and prevent UB are at an early stage of development and evaluation and their ability to impact the prevalence of UB is uncertain. While we identified 42 reports of interventions, most were small in scope, implemented in only one organisation, focused on individual-level contributors to UB, and only delivered to a subset of organisational staff. While UB is associated with reduced patient safety in both simulation and cross-sectional studies [1, 10, 11], no intervention measured changes in patient safety; however, some studies did measure changes in staff wellbeing (e.g. [156, 169]).

Our organisation of strategies according to their level of implementation, mechanism of action and the Key Dynamics, provides guidance on which strategies are appropriate in different circumstances. This is schematically represented in our overall programme theory diagram in Fig. 6. This overall programme theory broadly illustrates “how interventions can work to reduce, mitigate, or prevent UB, why, and under which circumstances”. It is important to note that this schematic only reflects strategies to address UB in acute care identified in this review.

We found that interventions in acute healthcare are preoccupied with individual behaviour, despite most contributors to UB being organisational and systemic [20]. Other reviews of interventions to reduce UB (including outside of healthcare) have highlighted this, noting that “the assumption that workplace mistreatment will be lessened if more people know about it, know how to recognise it and be more assertive in their responses to it (…)is a flawed assumption” [24]. An overly individual focus could lead to interventions being undermined by unaddressed systemic contributors (e.g. frustrating workplace designs, and a lack of job resources). An implication of this that future interventions should move towards addressing these systemic drivers as a priority [8].

Our work supports other authors who identified the risk that certain reporting systems can lead to a “worsening of safety culture by eroding trust and respect among healthcare professionals and teams, which affects both patient safety and individual well-being” [182]. Thus, maintaining a focus on why it is important for UB to be addressed is urgent and essential, to ensure interventions benefit staff and patients and to avoid perceptions of being ‘tick-box exercises’ [160]. This implies that interventions should focus on fostering a culture that supports building psychological safety, relationships between staff, and the ability to openly and freely talk to one another to manage conflicts before they escalate, to increase likelihood of success.

Overall, we found that theoretical bases of interventions and how and why they were intended to work were not well-reported. No included reports presented logic models nor drew on contemporary behavioural science that may lead to, or at the very least, facilitate long-term behaviour change. This finding suggests that authors may not always understand how intervention components will produce the desired effects. This may delay the advancement in rigorous research and understanding of UBs that is achieved by long-term repeated/iterative testing and developing of theories and logics. Other authors reviewing interventions in this area have suggested a lack of grounding in theory may be because “organizations are initiating their own research rather than turning to experts and academics to conduct analyses” [26], as highlighted in Key Dynamic 12. It is possible that provision of further guidance, such as in this review, will help others in practice to feel comfortable drawing on more theory-based interventions. Future reports of interventions should present logic models and make explicit any assumptions regarding how they intend to reduce UB with their chosen intervention design.

Key Dynamic 10 emphasises how existing research has been conducted with little regard to the additional burden of UB that women, staff from minority backgrounds, or with disabilities, experience. Only one intervention sought to address racist UB in acute care [82], and no others addressed this issue. Furthermore, sexual assault and sexism remain prevalent issues in the UK NHS and healthcare systems and societies worldwide, together with other known widespread issues such as racism, and disability and discrimination against LGBTQ + people. For example, over 4000 NHS staff between 2017 and 2022 were accused of rape, sexual assault, harassment, stalking or insults towards other staff or patients and only 576 have faced disciplinary action [183]. Similarly, in Australia, a survey of UB across seven hospitals found that 14.5% of staff had experienced “extreme” UB such as sexual assault, inappropriate touching and physical violence [1]. Intervention architects may assume that addressing UB in general may work to address issues such as misogyny, microaggressions and racism. We also found no mention of co-design of interventions with stakeholders by intervention architects, which may have resulted in interventions not targeting key outcomes relevant to the healthcare workforce. Our findings indicate the experiences of women and minoritised staff are unlikely to be addressed without specific effort. Further interventions must consider and addresses the inequitable impact of UB on female staff and staff from minoritised backgrounds as a core aspect of intervention design.

UB is a pervasive issue which negatively impacts patient safety and erodes staff wellbeing. UB is yet to be sufficiently addressed by existing interventions, despite the urgent need to do so. Most intervention studies were conducted in the USA, Australia and Canada. The majority of these do not address systemic contributors to UB and rely on education or training workshops to boost individual knowledge and awareness of UB, improve ability for staff to speak up, or seek to identify problematic individuals. Such approaches may reduce prevalence of UB; however, it is currently unclear whether these interventions positively impact organisational culture, patient safety or staff psychological wellbeing. Interventions that focus on both individual and systemic contributors are required to effectively reduce UB. Issues such as lack of trust in management caused by pervasive, unaddressed UB presents a significant barrier to staff engagement with interventions. Fostering a culture that supports staff on the receiving end of UB to safely speak up can signal that UB is not tolerated. Future interventions would benefit from drawing on modern behavioural and implementation science principles, incorporating economic analyses, focusing on systemic issues that produce UB, and acknowledging and addressing the additional burden of UB experienced by women and minoritised staff.