Developing a novel typology of unprofessional behaviours between healthcare staff: a best fit framework synthesis

Background: Unprofessional behaviours such as bullying, harassment, and microaggressions negatively affect patient safety and staff psychological wellbeing in healthcare systems globally. These behaviours do so by: (i) inhibiting health care professionals’ abilities to speak up to raise safety concerns; (ii) impairing team communication and individuals’ concentration; and (iii) promoting tolerance of bad practice. Unfortunately, there is little consensus in practice or academia about how these behaviours are defined. This can lead to an underestimation of the prevalence of these behaviours, inhibition of speaking up by victims and bystanders, and reduced accountability by those who enact these behaviours. We aimed to map definitions of unprofessional behaviours between staff to understand their similarities and differences and to develop a useful typology for theory-informed interventions. Methods: We used a six-step modified best-fit framework synthesis methodology to formulate our new typology, as a part of a wider realist review project. We employed a systematic approach to develop a framework for understanding UB. First, we identified relevant literature through a systematic search of Embase, CINAHL and MEDLINE databases (and more) (n = 146 sources). An initial framework outlining the dimensions of unprofessional behaviours was then constructed based on extracted definitions. Terms from included studies were then coded against this framework, with new dimensions introduced as needed to accommodate terms that did not align with existing categories. The resulting framework was refined iteratively and validated through stakeholder engagement, enhancing its relevance and validity. Results: We identified 37 behaviours drawing on 146 literature sources and found little consensus in how unprofessional behaviours between staff are defined in the academic literature. By collating definitions, we identified five dimensions inherent to unprofessional behaviours between staff namely: visibility; inherent frequency; whether they are highly targeted; if behaviours target protected characteristics (personal attributes that are legally safeguarded against discrimination in the UK and many other countries, such as race, sex or religion); if behaviours are physical; and if hierarchy is required. These dimensions enabled formulation of the typology with increased understanding of the differences between unprofessional behaviour types. Conclusions: We found that poor and inconsistent understanding of unprofessional behaviour could undermine interventions by inhibiting speaking up, enabling instigators to avoid accountability, and inhibiting ability to measure unprofessional behaviour and address it. Our typology provides a useful resource for academics, healthcare organisations, intervention architects, and individuals who are seeking to understand and clarify the range of unprofessional behaviours that may be encountered in healthcare settings.