This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Researchers found that unprofessional behaviour such as rudeness or bullying may become embedded in the workplace when staff are disempowered, teams lack cohesion, and managers are unaware of the behaviour.
They found that unprofessional behaviour can reduce staff wellbeing, contribute to mental and physical health problems among staff, impact patient safety and compromise the quality of patient care. Unprofessional behaviour was most likely to be directed at staff who are female, new, disabled or from minority groups.
The researchers suggest that improved working conditions and staff collaboration could reduce unprofessional behaviour in healthcare. They hope their findings will encourage healthcare organisations to tackle unprofessional behaviour.
More information about civility and respect at work can be found on the NHS England website.
The issue: Why might some healthcare staff behave unprofessionally?
Unprofessional behaviours (rudeness, harassment and bullying, for instance) in healthcare distress and harm colleagues. The 2023 NHS staff survey revealed that 18% of NHS staff experienced harassment, bullying or abuse from their colleagues; 10% reported these behaviours from their managers.
Unprofessional behaviours increase staff burnout, absences and resignations. They impact patient care and safety. Researchers investigated why staff might behave unprofessionally and what impact that behaviour could have. This study is part of a larger research project that aims to develop interventions to improve workplace behaviour in healthcare.
What’s new?
Researchers examined 109 reports, including journal articles and grey literature (written by professional organisations, for example). They worked with professional standards bodies, patients, members of the public, and healthcare staff who had lived experience of unprofessional behaviour (either witnessing the behaviour, or being on the receiving end). They used a review method called realist synthesis which goes beyond asking whether something works, and asks for whom it works, in what circumstances and why. The aim is to generate a theory that can be tested further.
The researchers identified 5 main drivers of unprofessional behaviour:
- disempowered staff who feel undervalued
- harmful workplace processes and cultures (high job demands because of understaffing, for instance, and senior staff who themselves display unprofessional behaviour)
- a lack of team cohesion and support, which can be caused by shift working
- reduced ability to speak up
- managers who lack awareness or recognition of unprofessional behaviours, and take no action.
The drivers of unprofessional behaviour also reduced the ability of staff to cope with it. Staff could feel unable to report, challenge or address incidents. This in turn increased unprofessional behaviour and reduced staff wellbeing (contributing to mental and physical health problems such as burnout).
Staff who are female, new, disabled or from ethnic minorities were most likely to be on the receiving end of unprofessional behaviour. People’s response to unprofessional behaviour varies according to their circumstances, for instance whether they feel valued and have a supportive team.
The study found that unprofessional behaviour could reduce patient safety and the quality of care provided through:
- staff losing confidence in their abilities, and having impaired concentration
- medical errors and patient safety concerns being ignored or going unreported
- breakdown of staff relationships, communication and trust.
Why is this important?
A better understanding of the drivers of unprofessional behaviour will help address it effectively and could improve care and reduce costs. A hospital in the US reduced staff absences by 38% after it introduced an intervention to reduce unprofessional behaviour.
The documents included in this study covered settings similar to the NHS, plus studies reporting an intervention (there is little UK research on interventions). Further research could test the theories generated and explore whether they apply to different settings such as primary care, or private healthcare institutions.
What’s next?
The researchers have produced guidance to help healthcare professionals address unprofessional behaviours; they plan to explore how the guidance is being used.
To date, the focus has been on individual ‘bad apples’. However, teams and organisations are responsible for addressing unprofessional behaviour, and the researchers call for the focus to shift from individuals who behave unprofessionally to workplace culture.
The researchers suggest that interventions need to:
- address systemic problems, and foster a work environment in which staff feel able to speak up rather than just removing people who behave unprofessionally
- encourage staff to intervene when they see unprofessional behaviour or suspect it is about to happen (when safe to do so)
- support managers to listen and act on staff concerns
- promote trust; the behaviour of managers and senior leaders needs to match the values being called for and they need to be held to account for historic instances of unprofessional behaviour
- be designed for all groups of staff across the organisation and benefit everyone
- be flexible and tailored to different situations, even if this makes them difficult to evaluate.
Do I agree with these findings?
How can I act on the new knowledge?
You may be interested to read
This is a summary of: Aunger JA, and others. Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review. BMC Health Services Research 2023; 23: 1326.
An NIHR Journals Library report from the same project: Aunger JA, and others. Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review. Health and Care Delivery Research 2024; 12: 25.
A video by one of the researchers: How unprofessional behaviours between healthcare staff arise and can be addressed
An NIHR Evidence summary about Freedom to speak up guardians.
Workplace bullying and harassment of doctors: A review of recent research from the British Medical Association.
Promoting a positive working environment from the British Medical Association
Workforce race inequalities and inclusion in NHS providers from The King’s Fund.
Funding: This study was funded by the NIHR Health and Social Care Delivery Research programme.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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