Title: Strategies to address unprofessional behaviours among staff in acute healthcare settings: a realist review
Funder: Department of Health and Social Care

Abstract: The unprofessional behaviours of healthcare staff towards each other are known to be common. In poor workplaces such behaviours are sometimes considered ‘normal’. But they can really affect an individual’s ability to work without fear and stop them speaking up to those in authority when things are not right. These behaviours affect patient safety and staff experience and well-being. This study builds on previous research by the team and others by focusing on unprofessional behaviours between staff groups in acute care settings (hospitals). These behaviours include rudeness, overstepping boundaries, verbal aggression, sexual and racial harassment and bullying. They affect all staff, but are seen more often in certain professions such as ambulance trusts, or groups including people from black and minority ethnic groups. Present approaches to address unprofessional behaviours often focus on individuals and do not take an organisation wide approach. They also often focus on only one type of unprofessional behaviour. Managers and others in positions capable of implementing change do not always know what to do and which strategies are best to use with which staff groups to address specific types of behaviours. This review will provide that information._x000D_ _x000D_ The aim of the project is to improve understanding of how, why and in what situations staff unprofessional behaviours can be best reduced, managed and prevented. To do this we will use a literature review method called a realist review which is different to other review methods. This focuses on understanding not only if interventions work (or not) but how they work, why, and for whom they work. Other types of literature reviews exist, but they often look at how things work ‘on average’ and do not take enough notice of the complexity of the problem and the different staff situations, work practices and varying contexts. Realist reviews focus on understanding not only if interventions work (or not) but how they work, why, and for whom they work and are useful in exploring different contexts. We will analyse a wide range of relevant literature (not only academic journal articles) and will identify the factors that contribute to staff unprofessional behaviours. We will build on these research findings to develop a follow-on intervention study to evaluate whether these strategies work when they are put into practice._x000D_ _x000D_ We have formed a team who are experts in unprofessional behaviours, psychological safety and realist reviews to undertake the research. We will share the study findings with a stakeholder group which includes patient and public representatives as well as healthcare staff with experience of unprofessional behaviours. This group will draw on their experiences and knowledge to work with the researchers to understand the findings and will help to design and develop evidenced-based guidelines for NHS managers to reduce and prevent unprofessional behaviours. Findings will be shared via reports, academic publications and plain English summaries to reach a wide audience, including patients and the public, NHS trusts, NHS Employers, and NHS England. We will also use inventive methods share the study findings including a short film, animations, pictorial representation of our findings (info-graphics) and interactive drama performances.

Lay abstract: Introduction: The NHS needs healthy, motivated staff to provide high quality patient care but this can be compromised by unprofessional behaviours in the workplace. Unprofessional behaviours between staff are widespread and often normalised within workplaces. Yet they significantly affect an individual’s ability to work without fear and speak up when things are not right. Unprofessional behaviours include incivility, overstepping boundaries, disruptive or bullying behaviours. These behaviours affect all staff, but disproportionately so those in certain professions such as ambulance trusts, or groups including black and minority ethnic groups. Current strategies to address unprofessional behaviours often take an individualised and localised approach. Rarely do strategies seek to address issues at a higher, organisational level. Whilst there is an awareness that change is needed to improve workplace culture, it is less clear to leaders and managers which approaches are most effective. This study will produce evidenced-based guidelines to outline which strategies work to reduce and mitigate unprofessional behaviours for which specific professional groups and in what circumstances._x000D_ _x000D_ Aim: To improve context-specific understanding of how, why and in what circumstances healthcare staffs’ unprofessional behaviours in acute healthcare settings can be best attenuated, managed and mitigated._x000D_ _x000D_ Methods: An evidence synthesis (realist review) to understand 1) differences, similarities and ambiguities between terms referring to unprofessional behaviours and how these are used by different professional groups in acute healthcare settings; 2) the contexts for unprofessional behaviours; the mechanisms which trigger different types of unprofessional behaviours; and the outcomes of unprofessional behaviours on staff, patients and the wider system of healthcare; 3) which strategies designed to mitigate, manage and prevent unprofessional behaviours are most useful, in what circumstances, for whom and why._x000D_ _x000D_ Results: The project will summarise how, why and in what circumstances unprofessional behaviours between staff in acute care settings occur; and what strategies can remediate the situation for different staff groups. This will be supported by gaining an initial understanding of the plethora of terms used in relation to unprofessional behaviours. Such knowledge will produce actionable theory to inform recommendations and resources. This will help policy makers, health services decision makers, and local team leaders to select, tailor, implement and evaluate contextually-sensitive strategies to tackle unprofessional behaviours. This will also inform the development of a follow-on empirical evaluation of strategies and interventions in practice. _x000D_ _x000D_ Outputs: Using evidence from our review as well as implementation theory and stakeholder involvement, we will identify and develop a range of resources and tools for NHS managers/leaders. These collaboratively produced resources will enable NHS managers/leaders to deploy the most effective strategy tailored for different contexts, circumstances and professional groups. Innovative methods will be used to develop these resources such as film, animation, info-graphics and interactive performances. Plain English summaries will facilitate wider dissemination, as will a specific dissemination event for key stakeholders including regulators, Royal Colleges, PPI, NHS Employers and NHS England.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE