Endemic unprofessional behaviour in health care: the mandate for a change in approach

Pervasive bullying, discrimination and sexual harassment are increasingly hard to ignore, yet evidence of effective interventions is lacking

Unprofessional behaviour is sufficiently widespread in the Australian health care system that it could be considered endemic. The 2016 survey of the Victorian Public Sector Commission found that 25% of staff in health agencies experienced bullying,1 and in a 2014 survey of the Australian Nursing and Midwifery Federation, 40% of nurses reported bullying or harassment in the previous 12 months.2 In 2015, the Royal Australasian College of Surgeons surveyed 3516 surgical Fellows, trainees and international medical graduates and found that 49% had been subjected to discrimination, bullying, harassment or sexual harassment.3 The Australasian College for Emergency Medicine released in 2017 its survey results: 34% of respondents had experienced bullying, 21.7% discrimination, 16.1% harassment and 6.2% sexual harassment.4 Thus, unsurprisingly, the 2016 Senate inquiry into the medical complaints process concluded that bullying, discrimination and harassment levels remain disconcertingly high despite the apparent “zero tolerance” approach reported by medical administrators and colleges.5

Bullying, discrimination and harassment are just the tip of the iceberg. Unprofessional or disruptive behaviour encompasses a wide spectrum that includes conduct that more subtly interferes with team functioning, such as poor or ambiguous communication, passive aggression, lack of responsiveness, public criticism of colleagues, and humour at others’ expense.6 Although unprofessional behaviour is common,6 the true prevalence is likely to be significantly underestimated, with widespread under-reporting. Little is known of the experiences of non-clinical, non-managerial staff in the health care system, who in general have considerably less power and status to combat unprofessional behaviour.

Impact of unprofessional behaviour

Unprofessional behaviour is associated with poor staff psychological wellbeing, including stress, reduced teamwork and communication, and loss of concentration.7-9 This behaviour can negatively affect staff satisfaction10 and staff absenteeism11 and retention, leading to costly staff turnover,12 and is associated with patient dissatisfaction,13 increased medico-legal risk13,14 and significant financial costs.15 Health professionals consistently recognise the link between unprofessional behaviour and threats to patient safety and wellbeing.5,9,10

Less well understood is the emerging evidence that even low level unprofessionalism is a significant risk to patient safety. For example, a randomised controlled trial showed that neonatal intensive care unit teams subjected to rudeness during a simulated management of a deteriorating infant performed significantly worse than teams treated respectfully by their expert observer. Rudeness resulted in less information sharing between team members, which compromised diagnostic performance and reduced help-seeking behaviour, contributing to poorer procedural performance compared with teams treated with civility.16 A large, multisite study in the United States showed that patients whose surgeons received a high number of unsolicited patient reports of negative behaviour (eg, being rude or dismissive of patient questions, unprofessional communication with staff) experienced a 13.9% higher surgical and medical complication rate compared with surgeons with few such reports.17

Growing concerns regarding unprofessional behaviour have contributed to increased attention in medical and health programs on professional identity formation as the foundation for professionalism.18,19 Everyday interactions with colleagues are a significant contributor to an individual’s development of professional identity.20 Humiliation, belittling and verbal abuse of medical students and trainees are common and, in some situations, normalised in Australian hospitals.5,21 Interviews with senior Australian clinicians show that early experiences of role models affect professional identity formation and endure for many decades.20 Tackling unprofessional behaviour must start with university, college and workplace-based training programs, but these will have limited success without significant culture change programs across health care organisations.

Workplace interventions to reduce unprofessional behaviour: limited evidence base

The 2016 Senate inquiry recommended that governments, hospitals, specialty colleges and universities “commit to ongoing and sustained action and resources to eliminate [bullying and harassment],”5 but provided little direction as to how this should occur. Professional colleges have sought to tackle this issue by improving complaints mechanisms and an emphasis on training, such as the online education programs mandated by the Royal Australasian College of Surgeons.

For hospitals seeking to bring about significant cultural change in reducing unprofessional behaviour, there is limited evidence of effective organisational interventions. A 2017 Cochrane review22 of interventions to prevent bullying in the workplace identified only five studies and noted the low quality of available evidence. These studies predominantly described small scale interventions, with few attempts to implement multi-organisational change. The review authors concluded that “we need large well-designed controlled trials of bullying prevention interventions ... Future studies should employ validated and reliable outcome measures of bullying and a minimum of 6 months follow-up”.22

Of available studies, interventions that target bullying and harassment have received most attention.22 However, the insidious nature of incivility and its potential impact on care warrants specific consideration. The Civility, Respect and Engagement in the Workplace (CREW)23 approach, developed and implemented across the US Veterans Health Administration nearly 20 years ago, seeks to encourage work units to identify areas of working relationships that could be improved and to formulate an action plan. Staff are assisted with expert facilitation and tools to support this process designed to last for a period of 6 months. The focus and types of actions taken are therefore locally instantiated. The adaptive, voluntary elements of the organisational change program are viewed as program strengths. There is some evidence that this program has been effective. A controlled before-and-after study across multiple US Veterans Affairs sites showed an improvement in staff survey civility and satisfaction scores.24 A study of eight health units in Canada adopting a similar approach also showed improvements in staff-reported levels of workplace civility, which continued 12 months after the implementation.23 However, subsequent evaluations are scant and there has been no study assessing whether care practices improved as a consequence.

Organisational professional accountability programs

Professional accountability programs are a relatively new approach to managing unprofessional behaviour in hospitals. These programs seek to call out unprofessional behaviour by removing the barrier of having to report this type of behaviour to superiors, who hold the power over career progression. Staff can report negative or positive behaviour anonymously using an online system. The purpose is not to investigate incidents, but to have trained peer messengers convey to the subject of the report the perceived effects of their behaviour on others. The intention is to encourage reflection and behaviour change. Repeated or serious reports prompt more formal disciplinary actions. Identifying reporting trends or clusters allows organisations to gain a more accurate picture of patterns of problem behaviour. Professional accountability programs postulate that early intervention in workplace behaviour should lead to positive behavioural change and avoid escalation to bullying or harassment. Such programs signal an organisation’s desire to act and switch the focus of improving organisational culture to “everybody’s business”. Importantly, these programs do not rely on problem individuals voluntarily engaging with the prevention program.

The Vanderbilt University Medical Center described early experience with this approach and concluded the model was feasible, with 372 reports made in the first 36 months (344 about physicians and 28 about advanced practice professionals), 164 physicians were associated with between one and two reports, and 34 received three or more.25 The authors suggested that these results indicated that most professionals self-regulate after receiving an initial report.

Professional accountability programs that draw on these US models are now being seen in Australian hospitals.26 However, there is as yet no published evidence of their effectiveness to reduce unprofessional behaviour, improve clinical outcomes or create significant organisational cultural change over time. Further, these programs have largely targeted the medical profession, despite compelling evidence that unprofessional behaviour is pervasive across the health workforce.1,2 Little is known about how these programs work in practice, or of the experiences of staff who participate in them.

Late 2017 saw the commencement of the rollout of a professional accountability program titled “Ethos” across St Vincent’s Health Australia, comprising 18 400 staff in six public and nine private hospitals and 16 aged-care facilities. Ethos aims to “redefine normal” and tackle the problem of unprofessional behaviour across all staff groups.27 The program uses trained peer envoys who provide feedback about reported behaviour to colleagues in an informal, non-punitive manner. The program includes organisation-wide training of staff to increase their skills in identifying and dealing with unprofessional behaviour. Importantly, for the first time, this program will be subject to an extensive external evaluation over a 4-year period to deliver evidence of its effectiveness in reducing rates of unprofessional behaviour and improving patient outcomes.27

Cultural change as a necessity for a safe and sustainable health system

There are multiple system-wide initiatives underway to create a sustainable, effective and safe health care system — from the rollout of clinical information technology systems, guidelines and quality standards to increase appropriate care, to programs to reduce waste and overuse. Without addressing behaviour, teamwork and culture, these programs will have limited impact on optimising safety and quality of care. Further, issues of significant staff burnout and dissatisfaction, both recognised consequences of poor organisational cultures,28 threaten the sustainability of the health workforce. Yet, investment and research evidence to achieve fundamental change in the high level of unprofessional behaviour in the health system have been absent, despite widespread calls for action.

International attention has recently been drawn to allegations of unprofessional behaviour in other industries, from directors and actors in Hollywood to members of the British Parliament. However, the stakes in health care are greater with patient care at risk. Health care professionals more than anyone else understand the importance of evidence-based approaches to improving how people behave. It is time for health care to lead the way by adopting and rigorously evaluating organisational change programs.