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Aunger JA, Abrams R, Westbrook JI, Wright JM, Pearson M, Jones A, Mannion R, Maben J. 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 2024; 12:1-195. [PMID: 39239681 DOI: 10.3310/pamv3758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
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. Future work Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Justin A Aunger
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Ruth Abrams
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Judy M Wright
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Aled Jones
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Jill Maben
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Won MH, Hwang IS, Shin SH. Influence of patient safety perception and attitude on inpatients' willingness to participate in patient safety: An observation study. Medicine (Baltimore) 2024; 103:e39033. [PMID: 39029028 PMCID: PMC11398777 DOI: 10.1097/md.0000000000039033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
Patient safety (PS) in clinical settings focuses primarily on ensuring active patient participation. However, there is limited understanding of patients' willingness to participate. This study aimed to investigate the association between PS perception, attitude, and inpatients' willingness to participate in PS. This cross-sectional study was conducted with 295 inpatients admitted to a tertiary hospital in South Korea between May and July 2023. Structured questionnaires were used to collect the data. The collected data were subjected to various analytical techniques including descriptive statistics, t tests, Pearson correlation analysis, and multiple regression analysis. Willingness to participate in PS of inpatients showed a statistically significant difference in PS education experience (t = -2.69, P = .008). There was a significant positive correlation between PS perception and attitude (r = .54, P < .001). Additionally, willingness to participate in PS had significant positive correlations with PS perception (r = .62, P < .001) and PS attitude (r = .48, P < .001). The factors influencing willingness to participate in PS were PS perception (β = .51, P < .001) and attitude (β = .20, P < .001). Based on these research findings, it is important to provide inpatients with education and campaigns to improve their perceptions and attitudes toward PS. In addition, it is essential to develop programs that encourage and support patient engagement in PS in hospitals. These efforts will promote active implementation of PS activities by inpatients in clinical settings.
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Affiliation(s)
- Mi Hwa Won
- Department of Nursing, Wonkwang University, Iksan, Republic of Korea
| | - In Suk Hwang
- Nursing Department, Wonkwang University Hospital, Iksan, Republic of Korea
| | - Sun-Hwa Shin
- Department of Nursing, College of Nursing, Sahmyook University, Seoul, Republic of Korea
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Baniulyte G, Jajeh N, Kandhari S, Lin YM, Magill S, Malcolm L, McGuckin B, Morphet E, Goodall CA. Inappropriate behaviours in a dental training environment: pilot of a UK-wide questionnaire. Br Dent J 2023; 235:859-863. [PMID: 38066139 DOI: 10.1038/s41415-023-6553-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/02/2023] [Accepted: 06/21/2023] [Indexed: 12/18/2023]
Abstract
Incivility and inappropriate behaviour in the workplace are topics of growing interest due to their impact on patient care and safety. Several surveys and campaigns have emerged highlighting the existence of a problem. However, the true scale is difficult to ascertain. The aim of this study is to determine the existence of inappropriate behaviours within the UK dental training environment.An anonymous pilot questionnaire was distributed across multiple platforms reaching out to dental professionals within training environments, inviting responses between July 2022 and October 2022. A total of 215 responses were received. The vast majority (73.2%) felt that inappropriate behaviour is a problem within UK dental training. Senior colleagues were identified as perpetrators in 88% of responses. Most respondents (66%) reported feeling uncomfortable raising the issue, and when raised, 30% felt unsupported. Only 9% felt confident that action was taken after the issue was reported. Belittling was experienced and witnessed most commonly.The feedback received reveals the existence of inappropriate behaviours within dental training environments. Qualitative feedback indicates that if left unaddressed, the impact of such behaviour may persist long-term. Further research is required to address this issue, improve dental training conditions and job satisfaction.
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Affiliation(s)
- Gabriele Baniulyte
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom.
| | - Neda Jajeh
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Sunmeet Kandhari
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Yen Ming Lin
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Stephen Magill
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Lucy Malcolm
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Bronagh McGuckin
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Elizabeth Morphet
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
| | - Christine A Goodall
- Royal College of Physicians and Surgeons Glasgow, Dental Trainees´ Committee, Glasgow, Scotland, United Kingdom
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Aunger JA, Maben J, Abrams R, Wright JM, Mannion R, Pearson M, Jones A, Westbrook JI. Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review. BMC Health Serv Res 2023; 23:1326. [PMID: 38037093 PMCID: PMC10687856 DOI: 10.1186/s12913-023-10291-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023] Open
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 .
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Affiliation(s)
- Justin Avery Aunger
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
- NIHR Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK.
| | - Jill Maben
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Ruth Abrams
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Judy M Wright
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Aled Jones
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
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Maben J, Aunger JA, Abrams R, Wright JM, Pearson M, Westbrook JI, Jones A, Mannion R. Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review. BMC Med 2023; 21:403. [PMID: 37904186 PMCID: PMC10617100 DOI: 10.1186/s12916-023-03102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 10/04/2023] [Indexed: 11/01/2023] Open
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 .
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Affiliation(s)
- Jill Maben
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Justin Avery Aunger
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK.
- NIHR Midlands Patient Safety Research Collaboration, University of Birmingham, Birmingham, UK.
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Ruth Abrams
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Judy M Wright
- School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Mark Pearson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Aled Jones
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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Kolbe M, Goldhahn J, Useini M, Grande B. "Asking for help is a strength"-how to promote undergraduate medical students' teamwork through simulation training and interprofessional faculty. Front Psychol 2023; 14:1214091. [PMID: 37701867 PMCID: PMC10494543 DOI: 10.3389/fpsyg.2023.1214091] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/01/2023] [Indexed: 09/14/2023] Open
Abstract
The ability to team up and safely work in any kind of healthcare team is a critical asset and should be taught early on in medical education. Medical students should be given the chance to "walk the talk" of teamwork by training and reflecting in teams. Our goal was to design, implement and evaluate the feasibility of a simulation-based teamwork training (TeamSIM) for undergraduate medical students that puts generic teamwork skills centerstage. We designed TeamSIM to include 12 learning objectives. For this pre-post, mixed-methods feasibility study, third-year medical students, organized in teams of 11-12 students, participated and observed each other in eight simulations of different clinical situation with varying degrees of complexity (e.g., deteriorating patient in ward; trauma; resuscitation). Guided by an interprofessional clinical faculty with simulation-based instructor training, student teams reflected on their shared experience in structured team debriefings. Using published instruments, we measured (a) students' reactions to TeamSIM and their perceptions of psychological safety via self-report, (b) their ongoing reflections via experience sampling, and (c) their teamwork skills via behavior observation. Ninety four students participated. They reported positive reactions to TeamSIM (M = 5.23, SD = 0.5). Their mean initial reported level of psychological safety was M = 3.8 (SD = 0.4) which rose to M = 4.3 (SD = 0.5) toward the end of the course [T(21) = -2.8, 95% CI -0.78 to-0.12, p = 0.011 (two-tailed)]. We obtained n = 314 headline reflections from the students and n = 95 from the faculty. For the students, the most frequent theme assigned to their headlines involved the concepts taught in the course such as "10 s for 10 min." For the faculty, the most frequent theme assigned to their headlines were reflections on how their simulation session worked for the students. The faculty rated students' teamwork skills higher after the last compared to the first debriefing. Undergraduate medical students can learn crucial teamwork skills in simulations supported by an experienced faculty and with a high degree of psychological safety. Both students and faculty appreciate the learning possibilities of simulation. At the same time, this learning can be challenging, intense and overwhelming. It takes a team to teach teamwork.
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Affiliation(s)
- Michaela Kolbe
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
- Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland
| | - Jörg Goldhahn
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Mirdita Useini
- Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
| | - Bastian Grande
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
- Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland
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Vauk S, Seelandt JC, Huber K, Grande B, Kolbe M. Exposure to incivility does not hinder speaking up: a randomised controlled high-fidelity simulation-based study. Br J Anaesth 2022; 129:776-787. [PMID: 36075775 DOI: 10.1016/j.bja.2022.07.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 06/27/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Speaking up with concerns is critical for patient safety. We studied whether witnessing a civil (i.e. polite, respectful) response to speaking up would increase the occurrence of further speaking up by hospital staff members as compared with witnessing a pseudo-civil (i.e. vague and slightly dismissive) or rude response. METHODS In this RCT in a single, large academic teaching hospital, a single simulated basic life support scenario was designed to elicit standardised opportunities to speak up. Participants in teams of two or three were randomly assigned to one of three experimental conditions in which the degree of civility in reacting to speaking up was manipulated by an embedded simulated person. Speaking up behaviour was assessed by behaviour coding of the video recordings of the team interactions by applying 10 codes using The Observer XT 14.1. Data were analysed using multilevel modelling. RESULTS The sample included 125 interprofessional hospital staff members (82 [66%] women, 43 [34%] men). Participants were more likely to speak up when they felt psychologically safe (γ=0.47; standard error [se]=0.19; 95% confidence interval [CI], 0.09-0.85; P=0.017). Participants were more likely to speak up in the rude condition than in the other conditions (γ=0.28; se=0.12; 95% CI, 0.05-0.52; P=0.019). Across conditions, participants spoke up most frequently by structuring inquiry (n=289, 31.52%), proactive (n=240, 26.17%), and reactive (n=148, 16.14%) instruction statements, and gestures (n=139, 15.16%). CONCLUSION Our study challenges current assumptions about the interplay of civility and speaking up behaviour in healthcare.
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Affiliation(s)
- Stefanie Vauk
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Julia C Seelandt
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Katja Huber
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland
| | - Bastian Grande
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland; Institute of Anaesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Michaela Kolbe
- Simulation Centre, University Hospital Zurich, Zurich, Switzerland; ETH Zurich, Zurich, Switzerland.
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