ORCID

Abstract

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.

Publication Date

2026-01-24

Publication Title

BMC Health Services Research

Volume

26

Issue

1

Acceptance Date

2025-12-22

Deposit Date

2026-02-27

Funding

This article arose from ideas conceived during a project supported by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme with grant number 131606. Justin Aunger was also supported by the NIHR Midlands Patient Safety Research Collaboration. Jill Maben is supported by a National Institute for Health and Care Research (NIHR) Senior Investigator Award. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR or the HS&DR programme.

Keywords

Bullying, Healthcare, Interventions, Patient safety, Unprofessional behaviour, Workforce

Creative Commons License

Creative Commons Attribution 4.0 International License
This work is licensed under a Creative Commons Attribution 4.0 International License.

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