Article Text

How can interventions more directly address drivers of unprofessional behaviour between healthcare staff?
  1. Justin A Aunger1,2,
  2. Ruth Abrams2,
  3. Russell Mannion3,
  4. Johanna I Westbrook4,
  5. Aled Jones5,
  6. Judy M Wright6,
  7. Mark Pearson7,
  8. Jill Maben2
  1. 1Midlands Patient Safety Research Collaboration, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  2. 2School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
  3. 3Health Services Management Centre, University of Birmingham, Birmingham, UK
  4. 4Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
  5. 5School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
  6. 6School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
  7. 7Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
  1. Correspondence to Dr Justin A Aunger; j.aunger{at}


Unprofessional behaviours (UBs) between healthcare staff are widespread and have negative impacts on patient safety, staff well-being and organisational efficiency. However, knowledge of how to address UBs is lacking. Our recent realist review analysed 148 sources including 42 reports of interventions drawing on different behaviour change strategies and found that interventions insufficiently explain their rationale for using particular strategies. We also explored the drivers of UBs and how these may interact. In our analysis, we elucidated both common mechanisms underlying both how drivers increase UB and how strategies address UB, enabling the mapping of strategies against drivers they address. For example, social norm-setting strategies work by fostering a more professional social norm, which can help tackle the driver 'reduced social cohesion'. Our novel programme theory, presented here, provides an increased understanding of what strategies might be effective to adddress specific drivers of UB. This can inform logic model design for those seeking to develop interventions addressing UB in healthcare settings.

  • Professional Role
  • Safety culture
  • Patient safety
  • Quality improvement
  • Implementation science

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Unprofessional behaviours (UBs) between staff can include, but are not limited to, microaggressions, incivility, bullying and harassment.1 These behaviours have negative impacts on staff well-being, patient safety, organisational reputation and organisational costs2 and are unfortunately prevalent in healthcare systems worldwide.1 3 4 We recently published two papers from our recent realist review. One reported a programme theory (PT) explaining five types of key driver of UBs in acute care settings and how these work5. The other reported a PT drawing on 42 reports of interventions using 13 types of behaviour change strategies to reduce UB.6 To improve the effectiveness of interventions to reduce UB, we found that it is essential to directly target drivers of UB with strategies that address them.6 However, which strategies best address particular drivers of UB have not yet been articulated.7 8 This report sets out which behaviour change strategies address specific drivers of UB based on common underlying mechanisms of action.


Realist reviews seek to understand why an intervention may work (or not), for whom, in which contexts and why, through the generation of PTs using retroductive logic.9 These are generally depicted as context–mechanism–outcome (CMO) configurations.10 These mechanisms, in realist terms, can be defined as ‘changes in recipient reasoning that occur in response to resources introduced by an intervention’.11

In line with RAMESES guidelines,9 10 our first step was to build initial PTs by analysing 38 reports from organisations such as National Health Service (NHS) England, the King’s Fund and NHS Employers using NVivo V.12 for data organisation.12 13 We then tested and refined these theories against 110 additional studies (to December 2022) identified with systematic searches of Embase, CINAHL and MEDLINE databases, and grey literature repositories. Article selection involved screening records for inclusion, rigour and relevance. Full methodology including inclusion/exclusion criteria is reported elsewhere.5 6 12

This resulted in theories to explain how and why 13 types of behaviour change techniques or ‘strategies’ work to reduce or mitigate UB and what drives UB and how—reported separately elsewhere.5 6 Uniquely, this short report combines these two aspects of our analysis, whereby we mapped mechanisms underpinning drivers of UB5 against strategies which address these drivers6 to develop this overall explanatory PT.


Our review encompassed 42 reports of interventions to address UB,14–55 29 of which have been evaluated through various study designs. Figure 1 presents a PT diagram depicting which behaviour strategies target various mechanisms underlying drivers of UB, which driver categories are impacted by these strategies, and which individual drivers within these categories are targeted. This PT includes five major drivers of UB: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) a reduced ability to speak up and (5) lack of manager awareness and urgency.5 In table 1, we provide more details of these behaviour change strategies and how they target specific drivers of UB as well as how frequently each strategy type was used by the 29 included evaluated interventions. Online supplemental file 1 presents an alternative version of figure 1 designed specifically to map onto our PT published elsewhere and provides a further detailed version of table 1.5

Supplemental material

Figure 1

Diagram to depict which different behaviour change strategies target particular drivers of unprofessional behaviour (UB).

Table 1

Matching the 13 types of strategy (and individual strategies within these) against types of drivers of UB

Figure 1 highlights that many drivers of workplace disempowerment and harmful workplace processes are only addressed by workplace redesign strategies. Such workplace redesign strategies seek to facilitate staff autonomy, control and ownership of work; however, workplace redesign must occur at an organisational level and has only been used once in an evaluated intervention.16 Our work also shows that the most frequently used (often individual-focused) strategies, such as improving awareness and knowledge of UB, address few actual drivers of UB and therefore may not be as effective as other strategies.

Discussion and conclusions

Existing interventions have made little use of logic models and behavioural science principles in their design, meaning that the rationale behind choice of behaviour change strategies has been poorly articulated and not evidence-based.6 Our PT, presented in figure 1, is a starting point to inform logic model design for those seeking to design evidence-based interventions that address particular drivers of UB.56 To improve reporting, future research should align and operationalise these strategies against existing Behaviour Change Technique (BCT) frameworks.57

Our PT has also highlighted that many systemic drivers remain under-addressed. Predominantly, existing interventions have focused on individual or team strategies to address UB with less focus on more systemic, potentially difficult-to-implement strategies such as redesigning the workplace to reduce frustrations and increase staff ownership over work.6

We have produced a free evidence-based guide for addressing UB in healthcare, available at

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Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


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  • Contributors JAA drafted this article with input from all authors. This article was based on analysis performed by JAA, JM and RA, with input from all authors. RA, RM, JIW, AJ, JMW, MP and JM attained funding to support this research. All authors approved the final manuscript.

  • Funding This project was supported by the NIHR HS&DR programme with grant number NIHR131606. JA was also supported by the National Institute for Health and Care Research (NIHR) Midlands Patient Safety Research Collaboration (PSRC) with grant number NIHR204294.

  • Disclaimer The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR programme.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.