Like Justice Potter Stewart who famously said of pornography ‘I know what it is when I see it‘, most of us might struggle to define unprofessional behaviour but would readily recognise it. However, it is a serious and often un-discussed issue in medicine and a risk to patient safety, team-working and staff welfare. Doctors are also much more likely to find themselves facing fitness to practice proceedings for unprofessional behaviour than for any failure in clinical competence.
The University of Nebraska Medical Centre says:
“unprofessional conduct includes disruptive and intimidating behaviours that interrupt teamwork and undermine safe care.” (University of Nebraska Medical Centre)
The College of Physicians and Surgeons of Ontario describe:
“when the use of inappropriate words, actions or inactions by a physician interferes with…teamwork and quality healthcare delivery.” (College of Physicians and Surgeons of Ontario)
If professional behaviour is
“the set of values, behaviours and relationships that underpins the trust the public has in doctors” (RCP London, 2005)
then unprofessional behaviour is the breakdown of these facets which can ultimately jeopardise that trust. So what does this look like in practice? Well, the range is wide and spans the glaringly obvious through to the much more subtle yet ultimately damaging behaviours. There is typically a spectrum of behaviours ranging from the obviously aggressive, like physical assault or aggressive language, through passive aggressive to passive. Behaviours such as consistently undermining or belittling staff, hostile or inadequate note taking or refusal to comply with policies such as hand washing can equally be as disruptive to teamwork and the delivery of safe health care. Although only a small proportion of doctors display such behaviours the same small group of individuals tend to do so recurrently.
There is increasing evidence demonstrating the detrimental effects of unprofessional behaviour on patient care.
In one American study, 17% of pharmacists reported feeling pressurised to accept a medication order despite safety concerns on at least three occasions (ISMP 2004).
A further 7% reported being involved in a serious medication error where intimidation was a significant contributory factor (ISMP 2004).
Similar results in a second American study which surveyed over 4000 doctors and nurses. Fourteen percent of respondents reported being aware of a specific adverse event related to a disruptive behaviour episode (Rosenstein AH, 2008).
Unprofessional behaviours have consequences for organisations:
One longitudinal study analysed patient complaints and the relationship to legal action in a practice of 645 doctors. Poor communication and behaviour were the most common cause of most complaints as opposed to issues with clinical competence (Hickson, 2008).
Other studies have demonstrated decreased morale and organisational engagement in teams which contain a disruptive member (Williams, 2008).
Furthermore, the evidence suggests that when patients witness unprofessional or disruptive behaviour, it weakens their confidence in the clinician and the organisation (Hickson, 2002).
So why do we accept it and what can the individual clinician do? Role modelling, early intervention and reporting frameworks all play key roles and we will discuss this further in part two of this blog. In the interim please tell us your own personal stories of witnessing unprofessional behaviour and the effects this had.
In part two of this blog, we will discuss why this behaviour is often tolerated within healthcare organisations and steps we can make to ‘speak up’.
Dr Judith Tweedie is an ST7 Cardiologist and is currently a National Medical Director’s Clinical Fellow working at the Royal College of Physicians and the Faculty of Leadership and Management. She co-authored this blog with Dr Kevin Stewart who is Clinical Director of the Royal College of Physicians’ Clinical Effectiveness & Evaluation Unit.