Unprofessional behaviour in Australian hospitals

Inappropriate behaviour harms health workers and patients, and evidence‐based solutions are needed

Health care is the largest employment sector in Australia, more than 1.7 million workers (14% of all employees).1 Incivility, bullying, aggression, and negative workplace cultures seem endemic and have repeatedly been associated with poor workforce and clinical outcomes, but high quality evaluation of interventions for eliminating these behaviours are rare.2,3,4

In this issue of the MJA, Westbrook and her colleagues5 report associations between unprofessional behaviour, perceptions about organisational culture, and how hospitals deal with such behaviour. In their relatively large sample — 5178 hospital employees of various types in seven Australian hospitals — they found that 14% of employees reported experiencing extreme unprofessional behaviour at work, including assault, and almost 40% experienced incivility or bullying every week. This is consistent with findings from other research in Australia,6,7 as are findings that nurses and non‐clinical staff are affected more than medical practitioners, as are younger and less experienced health employees.

A key finding by Westbrook and colleagues5 concerns the role of speaking up, which they found was strongly associated with less frequent experience of negative behaviour, and with reduced impact of such behaviour on the individual's wellbeing. However, it may be that people who work in hospitals where rates of negative behaviour are lower are more able to speak up, so that the direction of the causality is unclear.

Speaking up also requires a workplace culture that allows it to be safe and effective, and to not cause disadvantage to employees or their careers. Such an environment is not facilitated by strong hierarchies, professional boundaries, and power differences between health professionals and other hospital workers, all of which are difficult to change. Training people in speaking up would be useful, although a focus on speaking up alone is unlikely to change the behaviour of those responsible for uncivil behaviour. Encouraging people to speak up needs to be supported by informal and formal independent complaints processes, and it is unclear whether such processes change the behaviour of perpetrators.

While awareness of the effects of unprofessional behaviour has grown and some hospitals have introduced programs,2 we do not know whether the situation is improving. A proliferation of small, cross‐sectional, anonymous surveys have focused on measuring prevalence rather than informing effective solutions. These surveys are difficult to compare because they used different measures and samples, and are prone to selection bias in terms of who responds and the contexts in which the survey respondents work. Anonymity can increase the reporting of stigmatised feelings and attitudes,8 but not survey response rates;9 respondents cannot be followed up to determine whether their experiences have changed; and survey responses cannot be linked to data on employee turnover, wages, job satisfaction, patient safety events, and clinical outcomes. Each survey seems a missed opportunity for properly advancing knowledge. While the lack of follow‐up is a major omission if trying to understand causes and to identify solutions, funding for large scale longitudinal surveys with individual follow‐up is difficult to obtain. The landmark Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of 10 000 doctors was an exception during its eleven annual waves of data collection.10

So how can we improve the evidence base? Measuring the prevalence of poor behaviour is important, but must be combined with longitudinal surveys of large representative samples, as well as more randomised controlled trials of interventions to obtain better evidence about potential solutions. Stronger carrots and sticks, including linkage with hospital accreditation, will be needed to motivate employers to undertake action; state governments, professional organisations and unions also need to play active roles. Further, workplace safety assessors and insurers should not restrict their attention to accidents and physical injuries, but also deal more effectively with mental health and workplace culture problems that cause harm. However, detailed evidence‐based solutions have not been described in the literature, and convincing governments to act and employers to effectively support employees requires evidence about the costs and benefits of such interventions.

The multifaceted drivers of poor medical care are complex, including human relationships11 that interact with cultures of power, sexual, social and ethnic differences, workplace cultures, and exposure to high workloads, long hours, and stressful and emotional situations.3 We are currently far from having effective national reporting systems that are transparent and safe and independent of the professions and employers. The responsibility to fix this situation should not lie with employees.