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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 .

Background Unprofessional behaviours of healthcare staff have negative impacts on organisational outcomes, patient safety and staff well-being. The objective of this study was to undertake a qualitative analysis of narrative responses from the Longitudinal Investigation of Negative Behaviours survey (LION), to develop a comprehensive understanding of hospital staff experiences of unprofessional behaviours and their impact on staff and patients. The LION survey identified staff experiences and perceptions related to unprofessional behaviours within hospitals. Methods Two open-ended questions within the LION survey invited descriptions of unprofessional staff behaviours across seven hospitals in three Australian states between December 2017 and November 2018. Respondents were from medical, nursing, allied health, management, and support services roles in the hospitals. Data were qualitatively analysed using Directed Content Analysis (DCA). Results From 5178 LION survey responses, 32% ( n  = 1636) of participants responded to the two open-ended questions exploring staff experiences of unprofessional behaviours across the hospital sites surveyed. Three primary themes and 11 secondary themes were identified spanning, i) individual unprofessional behaviours, ii) negative impacts of unprofessional behaviours on staff well-being, psychological safety, and employee experience, as well as on patient care, well-being, and safety, and iii) organisational factors associated with staff unprofessional behaviours. Conclusion Unprofessional behaviours are experienced by hospital staff across all professional groups and functions. Staff conceptualise, perceive and experience unprofessional behaviours in diverse ways. These behaviours can be understood as enactments that either negatively impact other staff, patients or the organisational outcomes of team cohesion, work efficiency and efficacy. A perceived lack of organisational action based on existing reporting and employee feedback appears to erode employee confidence in hospital leaders and their ability to effectively address and mitigate unprofessional behaviours.

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 .

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.

Behaviour that is disrespectful towards others occurs frequently in hospitals, negatively impacts staff, and may undermine patient care. Professional accountability programs may address unprofessional behaviour by staff. This article examines a whole-of-hospital program, Ethos, developed by St Vincent’s Health Australia to address unprofessional behaviour, encourage speaking up, and improve organisational culture. Ethos consists of a bundle of tools, training, and resources, including an online system where staff can make submissions regarding their co-workers’ exemplary or unprofessional behaviour. Informal feedback is provided to the subject of the submission to recognise or encourage reflection on their behaviour. Following implementation in eight St Vincent’s Health Australia hospitals, the Ethos Messaging System has had 2497 submissions, 54% about positive behaviours. Peer messengers who deliver ‘Feedback for Reflection’ have faced practical challenges in providing feedback. Guidelines for the team who ‘triage’ Ethos messages have been revised to ensure only feedback that will promote reflection is passed on. Early evidence suggests Ethos has positively impacted staff, although evaluation is ongoing. The COVID-19 pandemic has required some adaptations to the program.

Background Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos , implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. Method Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. Results Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool (‘Design quality and packaging’), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos (‘Goals and Feedback’, ‘Access to Knowledge and Information’). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. Conclusion Aspects of the inner setting (e.g., ‘Leadership Engagement’, ‘Tension for Change’) had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

Shun Yamashita,1,2 Maiko Sakamoto,1 Shizuka Yaita,1,2 Kaori Inoue,1 Yukari Mizoguchi,1 Yuki Hoshino,1 Manami Yamaguchi,3 Noriko Ide,4 Naoko E Katsuki,2 Masaki Tago,2 Yasushi Miyata,5 Yasutomo Oda1 1Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan; 2Department of General Medicine, Saga University Hospital, Saga, Japan; 3Graduate School of Medical Science, Saga University, Saga, Japan; 4Department of General Medicine, NHO Ureshino Medical Center, Saga, Japan; 5Department of Primary Care and Community Health, Aichi Medical University School of Medicine, Aichi, JapanCorrespondence: Shun Yamashita, Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga, 849-8501, Japan, Tel +81952343238, Fax +81952342029, Email sy.hospitalist.japan@gmail.comIntroduction: Understanding the perceptions of medical students and faculty members regarding unprofessional behavior is crucial to appropriately guide medical students’ behavior. This study aimed to clarify the differences in perceptions of unprofessional behavior in clinical settings among Japanese medical students and faculty members.Methods: This single-center, cross-sectional survey was conducted at the Faculty of Medicine, Saga University. Participants were faculty members who participated in a faculty development program on medical students’ unprofessional behaviors in December 2024 and fourth-year medical students who attended a similar lecture in January 2025. The survey items were determined through identifying common unprofessional behaviors based on previous reports and following a discussion with faculty members responsible for pre-graduate education. Participants were divided into faculty and student groups, and differences in perceptions were analyzed using logistic regression analysis.Results: Participants comprised 40 (response rate 22%) faculty and 65 (64%) students. The faculty group showed significantly lower perceptions of being unprofessional in the following behaviors than the student group: violation of privacy or confidentiality obligations (odds ratio 0.089, 95% confidence interval 0.010– 0.766); false statements or misrepresentation (0.180, 0.034– 0.940); inappropriate use of social networking services (0.150, 0.029– 0.762); fabrication or falsification of data (0.228, 0.005– 0.941); bullying, discrimination, and sexual harassment (0.047, 0.006– 0.383). Multivariate logistic regression analysis identified “bullying, discrimination, and sexual harassment (0.058, 0.007– 0.487)” as the only factor on which their perceptions differed significantly.Conclusion: Both faculty members and medical students perceived the unprofessional behaviors of medical students similarly, except in the cases of bullying, discrimination, and sexual harassment. However, since faculty members considered five behaviors to be less unprofessional, their perceptions regarding unprofessional behaviors need to be realigned so that they can better guide medical students toward becoming better professionals in the future, thereby improving patient outcomes.Keywords: unprofessional behavior, medical students, faculty members, difference of perception

Background Developing professionalism is a core task in medical education. Unfortunately, it has remained difficult for educators to identify medical students’ unprofessionalism , because, among other reasons, there are no commonly adopted descriptors that can be used to document students’ unprofessional behaviour. This study aimed to generate an overview of descriptors for unprofessional behaviour based on research evidence of real-life unprofessional behaviours of medical students. Methods A systematic review was conducted searching PubMed, Ebsco/ERIC, Ebsco/PsycINFO and Embase.com from inception to 2016. Articles were reviewed for admitted or witnessed unprofessional behaviours of undergraduate medical students. Results The search yielded 11,963 different studies, 46 met all inclusion criteria. We found 205 different descriptions of unprofessional behaviours, which were coded into 30 different descriptors, and subsequently classified in four behavioural themes: failure to engage , dishonest behaviour , disrespectful behaviour , and poor self-awareness . Conclusions This overview provides a common language to describe medical students’ unprofessional behaviour. The framework of descriptors is proposed as a tool for educators to denominate students’ unprofessional behaviours. The found behaviours can have various causes, which should be explored in a discussion with the student about personal, interpersonal and/or institutional circumstances in which the behaviour occurred. Explicitly denominating unprofessional behaviour serves two goals: [i] creating a culture in which unprofessional behaviour is acknowledged, [ii] targeting students who need extra guidance. Both are important to avoid unprofessional behaviour among future doctors.

Objective. Professional accountability programs are designed to promote professional behaviours between co-workers and improve organisational culture. Peer messengers play a key role in professional accountability programs by providing informal feedback to hospital staff about their behaviour. Little is known about the experiences of messengers. This study examined the experiences of staff who delivered messages to peers as part of a whole-of-hospital professional accountability program called 'Ethos'. Methods. Ethos messengers (EMs) across eight Australian hospitals were invited to complete an online survey. The survey consisted of I7 close-ended questions asking respondents about their experiences delivering messages to peers and their perceptions of the Ethos program. Four open-ended questions asked respondents about rewarding and challenging aspects of being a peer messenger and what they would change about the program. Results. Sixty EMs provided responses to the survey (response rate, 4I.4%). The majority were from nursing and medical groups (53.4%) and had delivered I-5 messages to staff (57.7%). Time as an EM ranged from less than 3 months to more than I2 months. A majority had been an EM for more than I2 months (80%; n = 40). Most agreed they had received sufficient training for the role (90.I%; n = 48) and had the skills (90.I%; n = 48), access to support (84.9%; n = 45) and time to fulfil their responsibilities (70.0%; n = 30). Approximately a third (34.9%; n = I5) of respondents indicated that recipients were 'sometimes' or 'never' receptive to messages. Challenging aspects of the role included organising a time to talk with staff, delivering feedback effectively and communicating with peers who lacked insight and were unable to reflect on their behaviour. Conclusions. Skills development for peer messengers is key to ensuring the effectiveness and sustainability of professional accountability programs. Training in how to deliver difficult information and respond to negative reactions to feedback was identified by EMs as essential to support their ongoing effectiveness in their role.

Background Hospital infection prevention and control (IPC) programs are designed to minimise rates of preventable healthcare-associated infection (HAI) and acquisition of multidrug resistant organisms, which are among the commonest adverse effects of hospitalisation. Failures of hospital IPC in recent years have led to nosocomial and community outbreaks of emerging infections, causing preventable deaths and social disruption. Therefore, effective IPC programs are essential, but can be difficult to sustain in busy clinical environments. Healthcare workers’ adherence to routine IPC practices is often suboptimal, but there is evidence that doctors, as a group, are consistently less compliant than nurses. This is significant because doctors’ behaviours disproportionately influence those of other staff and their peripatetic practice provides more opportunities for pathogen transmission. A better understanding of what drives doctors’ IPC practices will contribute to development of new strategies to improve IPC, overall. Methods This qualitative case study involved in-depth interviews with senior clinicians and clinician-managers/directors (16 doctors and 10 nurses) from a broad range of specialties, in a large Australian tertiary hospital, to explore their perceptions of professional and cultural factors that influence doctors’ IPC practices, using thematic analysis of data. Results Professional/clinical autonomy; leadership and role modelling; uncertainty about the importance of HAIs and doctors’ responsibilities for preventing them; and lack of clarity about senior consultants’ obligations emerged as major themes. Participants described marked variation in practices between individual doctors, influenced by, inter alia, doctors’ own assessment of patients’ infection risk and their beliefs about the efficacy of IPC policies. Participants believed that most doctors recognise the significance of HAIs and choose to [mostly] observe organisational IPC policies, but a minority show apparent contempt for accepted rules, disrespect for colleagues who adhere to, or are expected to enforce, them and indifference to patients whose care is compromised. Conclusions Failure of healthcare and professional organisations to address doctors’ poor IPC practices and unprofessional behaviour, more generally, threatens patient safety and staff morale and undermines efforts to minimise the risks of dangerous nosocomial infection.