Factors leading to lapses in professional behaviour of Gynae residents in Pakistan: a study reflecting through the lenses of patients and family, consultants and residents.

INTRODUCTION: Professional behaviour is the first manifestation of professionalism. In teaching hospitals, the residents can be considered vulnerable to lapses in professional behaviour when they fail to meet the set standards of professionalism. Residents of some specialties are more at risk of lapses in professional behaviour due to the demanding nature of work. Research focusing on the behaviour of residents in the field of Gynae and the underlying factors contributing to such behaviour is notably lacking in the literature. Additionally, there is a gap in understanding the perspectives of patients from Pakistan on this matter, as it remains unexplored thus far, which constitutes the central focus of this study. An increase in complaints lodged against Gynae resident's professional behaviour in Pakistan Citizen Portal (PCP) was observed. Therefore, an exploratory qualitative study was conducted to investigate the factors and rationales contributing to the lapses in resident's professional behaviour. The study collected the viewpoints of three stakeholder groups: patients and their families, consultants and residents. The study was conducted in three phases. First, the document analysis of written complaints was conducted, followed by face-to-face interviews (11 per group) conducted by trained researchers from an independent 3rd party. Finally, the interview data was transcribed, coded and analysed. In total 15 themes were identified from the interviews with 3 stakeholders, which were then categorized and resulted in 6 overlapping themes. The most prevalent lapse reported by all 3 stakeholders was poor verbal behaviour of residents. CONCLUSION: The highly ranked factors contributing to triggering the situation were associated with workplace challenges, well-being of residents, limited resources, patients and family characteristics, patients' expectations, lack of administrative and paramedic support, cultural factors and challenges specific to Gynae specialty. Another intriguing and emerging theme was related to the characteristics of patients and attendants which helped in understanding the causes and implications of conflicting environments. The value of competency also emphasized that can be accomplished by training and mentoring systems. The thorough examination of these factors by key stakeholders aided in accurately analysing the issue, its causes, and possible solutions. The study's findings will assist higher authorities in implementing corrective actions and offering evidence-based guidance to policymakers to improve healthcare system.

[Medical overuse, defensive medicine and new reform of professional mistake].

Reflecting on the inappropriateness (medical overuse) and on defensive medicine, the Authors wonder whether the new Italian reform of professional guilt, desired at all institutional levels, will actually contain the high economic costs produced by these large and widespread phenomena. After having characterized the medical overuse and the defensive medicine indicating the common traits and main differences, the reflection is conducted by exploring the many scientific evidence that does not document any causal link between the decriminalization of professional conduct and the containment of the costs produced by the prescriptive inappropriateness. They conclude by stating that, for their containment, a third reform of professional liability will not be helpful. Instead, it must focus on other issues, mainly addressing the excessive reliance on judicial recourse. It should provide for mandatory out-of-court conciliatory mechanisms and clarifying the protective umbrella of the doctor's non-criminality.

Sexual Boundary Violations by Doctors - Context, Regulatory Consequences and Preventive Strategies.

While sexual boundary violations by doctors (SBVs) are viewed with utmost seriousness by disciplinary bodies and tribunals, complaints of SBVs in Australia continue to increase. In 2023, the Australian Health Practitioner Regulation Agency (Ahpra) outlined a "blueprint" to protect patients better from sexual misconduct in healthcare: reform being considered in 2024, by Australian health ministers. Few analyses or studies have offered an overview of the prevalence, effects, and causes of SBVs, nor the duties, liabilities, possible disciplinary action against, and potential treatment of, doctors who commit them. This column offers such an overview, and considers, additionally, whether doctors who may have psychiatric disorders associated with their boundary violations would be suitable candidates for treatment. Ultimately, we contend that a purely "responsive" approach is inadequate, and preventive measures such as screening and more effective education should be considered in medical schools as a way of reducing the incidence of SBVs.

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals.

A key component of professional accountability programmes is online reporting tools that allow hospital staff to report co-worker unprofessional behaviour. Few studies have analysed data from these systems to further understand the nature or impact of unprofessional behaviour amongst staff. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system. Ethos has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. This study included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. Submissions that indicated the behaviour increased the risk to patient safety were identified. Descriptive summary statistics were presented for reporters and subjects of submissions about unprofessional behaviour. Logistic regression was applied to examine the association between each unprofessional behaviour (of the six most frequently reported in the Ethos submissions) and patient safety risk reported in the submissions. The descriptions in the reports were reviewed and the patient safety risks were coded using a framework aligned with the World Health Organization's International Classification for Patient Safety. Of 1310 submissions about unprofessional behaviour, 395 (30.2%) indicated that there was a risk to patient safety. Nurses made the highest number of submissions that included a patient safety risk [3.47 submissions per 100 nursing staff, 95% confidence interval (CI): 3.09-3.9] compared to other professional groups. Medical professionals had the highest rate as subjects of submissions for unprofessional behaviour with a patient safety risk (5.19 submissions per 100 medical staff, 95% CI: 4.44-6.05). 'Opinions being ignored' (odds ratio: 1.68; 95% CI: 1.23-2.22; P < .001) and 'someone withholding information which affects work performance' were behaviours strongly associated with patient safety risk in the submissions (odds ratio: 2.50; 95% CI: 1.73-3.62; P < .001) compared to submissions without a patient safety risk. The two main types of risks to patient safety described were related to clinical process/procedure and clinical administration. Commonly reported events included staff not following policy or protocol; doctors refusing to review a patient; and interruptions and inadequate information during handover. Our findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organizations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.

Unprofessionalism in anesthesiology: A qualitative study on classifying unprofessional behavior in anesthesiology residency education.

STUDY OBJECTIVE: This study aims to identify the domains that constitute behaviors perceived to be unprofessional in anesthesiology residency training programs. DESIGN: Qualitative study. SETTING: Anesthesiology residency training programs. PATIENTS: Not applicable. The participants involved residents, fellows, and faculty members purposefully sampled in four US-based anesthesiology residency programs. INTERVENTIONS: Participants were asked to submit examples of unprofessional behavior they witnessed in anesthesiology residents, fellows, or faculty members via a Qualtrics link. MEASUREMENTS: Not applicable. The behavior examples were independently reviewed and categorized into themes using content analysis. MAIN RESULTS: A total of 116 vignettes were collected, resulting in a final list of 111 vignettes after excluding those that did not describe behavior exhibited by anesthesiology faculty or trainees. Fifty-eight vignettes pertained to unprofessional behaviors observed in faculty members and 53 were observed in trainees (residents and fellows). Nine unprofessionalism themes emerged in the analysis. The most common themes were VERBAL, SUPERVISION, QUALITY, ENGAGEMENT, and TIME. As to the distribution of role group (faculty versus trainee) by theme, unprofessional behaviors falling into the categories of BIAS, GOSSIP, LEWD, and VERBAL were observed more in faculty; whereas themes with unprofessional behavior primarily attributed to trainees included ENGAGEMENT, QUALITY, TIME, and SUPERVISION. CONCLUSION: By reviewing reported professionalism-related vignettes within residency training programs, we identified classification descriptors for defining unprofessional behavior specific to anesthesiology residency education. Findings from this study enrich the definition of professionalism as a multi-dimensional competency pertaining to anesthesiology graduate medical education. This framework may facilitate preventative intervention and timely remediation plans for unprofessional behavior in residents and faculty.

Bad behavior in healthcare: an insidious threat to patients, staff, and organizations.

PURPOSE OF REVIEW: 'Bad' or unprofessional behavior (UPB) destroys communication, teamwork, and professional wellbeing, presenting a significant threat to patients and staff. Understanding what constitutes 'bad' or UPB and creating broad accountability for its cessation is imperative to patient-centered care and the survival of the multidisciplinary health workforce. RECENT FINDINGS: Despite organizational and legislative commitments to provide well tolerated work environments, UPB is endemic in healthcare and continues to harm patients, staff, and organizations. Historically, categories of UPB have been researched separately which dilutes the problem. Typically, these behaviors cluster, are interchangeable, and are committed by same perpetrators. Women, junior staff, and minority groups remain the most prevalent targets. Even low intensity UPBs among health staff dramatically impacts risk to patient lives, limits quality care, and destroys staff wellbeing. Targeted interventions must address all five roles impacted by UPBs: the target, patients, bystanders, the perpetrator, and the organization to effectively eliminate UPBs. Organizational leaders must demonstrate and uphold organizational values and be swift in addressing UPB to limit the impact on teams and patients. SUMMARY: UPB in the healthcare setting presents a multifactorial threat to patients, staff, and organizations. To ensure the delivery of high-quality patient care, and the wellbeing of the health workforce it is crucial to understand the insidious impact of UPB and target interventions across all five roles.

Addressing unprofessional behaviors in the clinical learning environment: lessons from a multi-year virtual, intergenerational, interdisciplinary workshop.

INTRODUCTION: Optimizing the clinical learning environment (CLE) is a medical education priority nationwide. MATERIALS AND METHODS: We developed a virtual, one-hour workshop engaging students, housestaff and faculty in small-group discussions of five case scenarios adapted from reported unprofessional behaviors in the CLE, plus didactics regarding mistreatment, microaggressions and bystander interventions. RESULTS: Over two sessions (2021-2022), we engaged 340 students and 73 faculty/housestaff facilitators. Post-session surveys showed significant improvement in participants' ability to recognize and respond to challenges in the CLE. DISCUSSION: Our innovative workshop, including scenarios derived from institutional reports of unprofessional behaviors, advanced participants' knowledge and commitment to improve the CLE.

Unprofessional behaviour of GP residents leading to a dismissal dispute: characteristics and outcomes of those who appeal.

BACKGROUND: Recognition of poor performance in General Practice trainees is important because underperformance compromises patients' health and safety. However, in General Practice, research on persistent underperformance while in training and its ultimate consequences is almost completely lacking. We aim to explore the unprofessional behaviours of residents in General Practice who were dismissed from training and who litigated against dismissal. METHODS: We performed a structured analysis using open-source data from all General Practice cases before the Conciliation Board of the Royal Dutch Medical Association between 2011 and 2020. Anonymised law cases about residents from all Dutch GP training programmes were analysed in terms of the quantitative and qualitative aspects related to performance. RESULTS: Between 2011 and 2020, 24 residents who were dismissed from training challenged their programme director's decision. Dismissed residents performed poorly in several competencies, including communication, medical expertise and most prominently, professionalism. Over 90% of dismissed residents failed on professionalism. Most lacked self-awareness and/or failed to profit from feedback. Approximately 80% failed on communication, and about 60% on medical expertise as well. A large majority (more than 80%) of dismissed residents had previously participated in some form of remediation. CONCLUSIONS: Deficiencies in both professionalism and communication were the most prevalent findings among the dismissed General Practice residents. These two deficiencies overlapped considerably. Dismissed residents who challenged their programme director's decision were considered to lack self-awareness, which requires introspection and the appreciation of feedback from others.

Characteristics and risk factors of pharmacist misconduct in New Zealand: a retrospective nationwide analysis.

BACKGROUND: Professional misconduct has evolved into a worldwide concern, involving various forms and types of behaviours that contribute to unsafe practices. This study aimed to provide insights into the patterns characterising pharmacist misconduct and uncover underlying factors contributing to such instances in New Zealand. METHODS: This research examined all cases of pharmacist misconduct sourced from the Health Practitioners Disciplinary Tribunal (HPDT) database in New Zealand since 2004. Characteristics of the sampled pharmacists and cases were extracted, followed by a systematic coding of the observed misconduct issues. Identification of risk factors was accomplished through content analysis techniques, enabling an assessment of their prevalence across various forms of misconduct. RESULTS: The dataset of pharmacist misconduct cases comprised 58 disciplinary records involving 55 pharmacists. Seven types of misconduct were identified, with the most commonly observed being quality and safety issues related to drug, medication and care, as well as criminal conviction. A total of 13 risk factors were identified and systematically classified into three categories: (1) social, regulatory, and external environmental factors, (2) systematic, organisational, and practical considerations in the pharmacy, and (3) pharmacist individual factors. The most frequently mentioned and far-reaching factors include busyness, heavy workload or distraction; health impairment issues; and life stress or challenges. CONCLUSIONS: The patterns of pharmacist misconduct are complicated, multifaceted, and involve complex interactions among risk factors. Collaborative efforts involving individual pharmacists, professional bodies, responsible authorities, policy-makers, health funders and planners in key areas such as pharmacist workload and well-being are expected to mitigate the occurrence of misconduct. Future research should seek to uncover the origins, manifestations, and underlying relationships of various contributing factors through empirical research with appropriate individuals.

Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review.

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 .

Hospital staff reports of coworker positive and unprofessional behaviours across eight hospitals: who reports what about whom?

BACKGROUND: Workplace behaviours of healthcare staff impact patient safety, staff well-being and organisational outcomes. A whole-of-hospital culture change programme, Ethos, was implemented by St. Vincent's Health Australia across eight hospitals. Ethos includes a secure online submission system that allows staff across all professional groups to report positive (Feedback for Recognition) and negative (Feedback for Reflection) coworker behaviours. We analysed these submissions to determine patterns and rates of submissions and identify the coworker behaviours reported. METHOD: All Ethos submissions between 2017 and 2020 were deidentified and analysed. Submissions include structured data elements (eg, professional role of the reporter and subjects, event and report dates) and a narrative account of the event and coworker behaviours. Descriptive statistics were calculated to assess use and reporting patterns. Coding of the content of submissions was performed to classify types of reported coworker behaviours. RESULTS: There were a total of 2504 Ethos submissions, including 1194 (47.7%) Recognition and 1310 (52.3%) Reflection submissions. Use of the submission tool was highest among nurses (20.14 submissions/100 nursing staff) and lowest among non-clinical services staff (5.07/100 non-clinical services staff). Nurses were most frequently the subject of Recognition submissions (7.56/100 nurses) while management and administrative staff were the least (4.25/100 staff). Frequently reported positive coworker behaviours were non-technical skills (79.3%, N=947); values-driven behaviours (72.5%, N=866); and actions that enhanced patient care (51.3%, N=612). Medical staff were the most frequent subjects of Reflection submissions (12.59/100 medical staff), and non-clinical services staff the least (4.53/100 staff). Overall, the most frequently reported unprofessional behaviours were being rude (53.8%, N=705); humiliating or ridiculing others (26%, N=346); and ignoring others' opinions (24.6%, N=322). CONCLUSION: Hospital staff across all professional groups used the Ethos messaging system to report both positive and negative coworker behaviours. High rates of Recognition submissions demonstrate a strong desire of staff to reward and encourage positive workplace behaviours, highlighting the importance of culture change programmes which emphasise these behaviours. The unprofessional behaviours identified in submissions are consistent with behaviours previously reported in surveys of hospital staff, suggesting that submissions are a reliable indicator of staff experiences.

Just Culture: How Do We Address Risky and Unprofessional Behaviors that Lead to Errors?

Unprofessional behavior in the procedural arena is associated with worse patient outcomes. This is thought to be due to breakdowns in communication structures and team dynamics. Behavioral issues are often uncovered during the investigation of serious event reports. Understanding differences in behavior deviations enables leadership to best address each type with an appropriate response. This allows institutions to address reckless behavior and unprofessionalism, while concomitantly creating a culture that fosters trust to promote self-reporting and sharing of information. These are characteristics of high-reliability organizations that produce sustained excellence in patient outcomes.

Perception and engagement in unprofessional behaviors of medical students and residents: a mixed-method study.

BACKGROUND: The present study aimed to investigate perception and engagement in unprofessional behavior of residents and medical interns and explore the factors affecting their engagement in unprofessional behavior. METHOD: This study has an explanatory (quantitative-qualitative) mixed-method design. This study was conducted at Shahid Sadoughi University of Medical Sciences in 2022-2023. Participants, including residents and medical interns (n = 169), were entered by stratified random sampling. A survey was conducted in the quantitative step. A by an unprofessional behavior in clinical practice questionnaire (29 items) was used. For each behavior, the participants were asked to report whether they (a) participated in the behavior and (b) stated that the behavior Is unprofessional. In the qualitative step, 17 participants contributed. The qualitative data were collected by semi-structured interviews and analyzed according to the conventional content analysis approach Graneheim and Lundman introduced. RESULTS: The highest ratio of participants' engagement in unprofessional behavior was reported in 'failure to introduce yourself and nurses and physician assistants to the patient and his family' (n = 145 (85.8%)). The results showed the proportion of participants who engaged in unprofessional behavior more than those who did not participate. There were associations between participants' engagement in each behavior and their perception of that particular behavior as unprofessional. (p = 0.0001). In the following behaviors, although the participants acknowledged that these behaviors were unprofessional, those who participated in the unprofessional behaviors were significantly more than those who did not participate: failure to comply with clinic regulations and policy (p = 0.01), eating or drinking in the hallway of the clinic (p = 0.01), medical negligence in duties in the clinic setting (p = 0.04) and failure to perform duties in teamwork (p = 0.04). The qualitative results were explored in a theme entitled "internalized unprofessional culture," including three categories "encouraging contextual risk factors towards unprofessionalism," "suppressing of unprofessionalism reporting," and "disbelieving professionalism as a key responsibility." CONCLUSION: The results indicated that most participants engaged in unprofessional behaviors. The findings resulted from the internalized unprofessional culture in the workplace. The findings showed that engagement in unprofessional behaviors resulted from personal and systemic factors. The weakness of responsibility recognition and identity formation as a professional facilitated the engagement in unprofessional behaviors at the personal level. Furthermore, systemic factors including the contextual risk factors (such as deficiency of explicit and hidden curriculum), and the suppression of unprofessionalism reporting mechanism as a hidden factor played an important role in normalizing unprofessional behavior and promoting engagement in unprofessional behaviors among the participants. Recognition of the nature and extent of students' unprofessional behaviors facilitates educational discussion among teachers and students in this field. The results might assist to establish an assessment system and feedback mechanism to solve the problem of the "failure to fail" problem. In addition, these results provide medical educators insights into the development of professional courses that equip learners with adherence to professionalism and coping skills to deal with unprofessionalism in the healthcare system.