Unprofessional behaviour is a challenge in academic medicine. Given that faculty are role models for trainees, it is critical to identify strategies to manage these behaviours. A scoping review was conducted to identify interventions to prevent and manage unprofessional behaviour in any workplace or professional setting.
A search of 14 electronic databases was conducted in March 2016, reference lists of relevant systematic reviews were scanned, and grey literature was searched to identify relevant studies. Experimental and quasi-experimental studies that reported on interventions to prevent or manage unprofessional behaviours were included. Studies that reported impact on any outcome were eligible. Two reviewers independently screened articles and completed data abstraction. Qualitative analysis of the definitions of unprofessional behaviour was conducted. Data were charted to describe the study, participant, intervention and outcome characteristics.
12,482 citations were retrieved; 23 studies with 11,025 participants were included. The studies were 12 uncontrolled before and after studies, 6 controlled before and after studies, 2 cluster-randomised controlled trials (RCTs), 1 RCT, 1 non-randomised controlled trial and 1 quasi-RCT. Four constructs were identified in the definitions of unprofessional behaviour: verbal and/or non-verbal acts, repeated acts, power imbalance, and unwelcome behaviour. Interventions most commonly targeted individuals (22 studies, 95.7%) rather than organisations (4 studies, 17.4%). Most studies (21 studies, 91.3%) focused on increasing awareness. The most frequently targeted behaviour change was sexual harassment (4 of 7 studies).
Several interventions appear promising in addressing unprofessional behaviour. Most of the studies included single component, in-person education sessions targeting individuals and increasing awareness of unprofessional behaviour. Fewer studies targeted the institutional culture or addressed behaviour change.
Citation: Tricco AC, Rios P, Zarin W, Cardoso R, Diaz S, Nincic V, et al. (2018) Prevention and management of unprofessional behaviour among adults in the workplace: A scoping review. PLoS ONE 13(7): e0201187. https://doi.org/10.1371/journal.pone.0201187
Editor: Valerio Capraro, Middlesex University, UNITED KINGDOM
Received: July 13, 2017; Accepted: July 10, 2018; Published: July 26, 2018
Copyright: © 2018 Tricco et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: SES is funded by a Tier 1 Canada Research Chair in Knowledge Translation and the Mary Trimmer Chair in Geriatric Medicine (University of Toronto Department of Medicine); ACT is funded by a Tier 2 Canada Research Chair in Knowledge Synthesis. This project was funded by the Department of Medicine, University of Toronto to SES. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Unprofessional behaviour, including bullying, has become a major issue in recent international news [1–3]. Academic medicine is not immune to unprofessional behaviour; it has been reported by medical students, residents and faculty [4–7]. A systematic review showed that almost 60% of medical students experienced at least one form of harassment or discrimination and the most common perpetrator was the consultant physician. Similarly, a review of resident mistreatment found that physicians of higher hierarchical power were the most common perpetrators . Surveys of physicians in various countries [7, 9–12] have shown that up to 98% have experienced unprofessional behaviour in the workplace. While the commonest perpetrators are patients or their families, it is not uncommon for co-workers or supervisors to be the perpetrators [7, 9–12].
The impact of unprofessional behaviour on victims is widespread and concerning. Workplace abuse is associated with stress, depression, anxiety and absence from work in those who experience it [13–17]. Of particular concern in health care is the impact of unprofessional behaviour on role modeling for trainees and on patient care .
Unprofessional behaviour is recognised as an institutional challenge in academic organisations [14, 18]. Some authors have suggested that it is embedded within a medical culture that perpetuates the cycle of unprofessionalism [14, 18]. As faculty members are role models for their trainees, it is critical that we understand strategies to prevent and manage these behaviours. Previous attempts to mitigate unprofessional behaviour include feedback to perpetrators and educational interventions [19, 20]. However, the effectiveness of these strategies, in particular targeting faculty in academic medical centres and universities, is not clear. As such, the aim of this scoping review was to identify interventions to prevent and manage unprofessional behaviour among adults in any workplace or professional setting.
We developed a protocol using the scoping review methods proposed by Arksey and ‘O’Malley  and further refined by the Joanna Briggs Institute . The review was conducted to inform the efforts of the Department of Medicine (DOM), University of Toronto, whose members provided feedback on the protocol. We registered the review through the Open Science Framework . Although the PRISMA statement has not been modified for scoping reviews, we used it to guide our reporting (S1 Table) .
Our eligibility criteria were defined using the ‘Population, Intervention, Comparison, Outcomes, Study designs, Timeframe’ (PICOST) components  and were verified by members of the Department of Medicine, University of Toronto.
Population: All individuals employed full-time or part-time in any workplace setting. Our preliminary literature searches indicated that few interventions were tested in academic medicine, which is why the scope was broadened to include any workplace setting.
Interventions: Interventions to prevent and manage unprofessional behaviours in the workplace were eligible. A preliminary search for systematic reviews revealed no standard definition or list of terms used to describe unprofessional behaviour (e.g. workplace bullying) but common themes identified in this preliminary review were used to inform the search, which are provided in S2 Table. Similarly, various unprofessional behaviours were considered ranging from ignoring phone calls from co-workers to verbal hostility, social exclusion, sexual harassment, and threats to professional status [26, 27].
Comparators: Usual care, other interventions or no intervention were eligible for inclusion.
Outcomes: All relevant outcomes were eligible for inclusion, such as institutional culture, prevalence of unprofessional behaviours, as well as retention and recruitment of staff, faculty or trainees.
Study designs: We included all experimental (randomised controlled trials (RCTs), quasi-RCTs), quasi-experimental (interrupted time series, controlled before and after) and observational (cohort, case control) studies. Systematic reviews and qualitative studies were not eligible for inclusion. No limitations were imposed with regard to year of publication, language or publication status.
Information sources and search strategy
An experienced information specialist (JM) developed our comprehensive literature search in consultation with the research team, which was executed by a library technician (AE). ‘Seed’ papers (or seminal papers in the field) were identified by Department of Medicine members to validate the search strategy. The search was peer reviewed by a second librarian (EC) using the PRESS Checklist . The search was revised and executed from inception until March 28, 2016 in the following databases: MEDLINE, EMBASE, CINAHL, The Cochrane Library, The Campbell Library, The Joanna Briggs Institute, Education Resources Information Centre (ERIC), PsycInfo, Social Work Abstracts, Sociological Abstracts, Dissertation Abstracts International, Dissertations & Theses Global, Criminal Justice Abstracts, National Criminal Justice Reference Service Abstracts, Business Source Complete, and ABI/IFNORM (S1 Text). We also conducted a search to identify difficult to locate and unpublished (or grey) literature using the Canadian Agency for Drugs and Technologies in Health checklist,  such as websites (e.g., Bullying Research Network, Workplace Bullying Institute) and thesis databases (S2 Text). To identify other potentially relevant articles, we asked experts in the field and searched the references of relevant systematic reviews identified during screening.
We removed duplicates and imported the literature search results into our proprietary software for screening titles and abstracts and full text articles . The inclusion criteria were used for screening citations during the title and abstract screening (i.e., level 1) and full-text article (i.e., level 2) screening. We completed calibration exercises prior to each stage of screening to ensure reliability across reviewers. Inter-rater agreement was calculated using percent agreement and set at a threshold of ≥75%. For level 1 screening, one pilot-test of 50 citations was conducted and 80% agreement was achieved. Subsequently, pairs of independent reviewers reviewed all titles and abstracts for inclusion (RC, SD, VN, PR, WZ). For full-text screening, one pilot-test of 25 full-text articles was conducted with 76% agreement achieved. Reviewer pairs then independently screened the full-text of potentially relevant articles to determine inclusion (RC, SD, VN, PR, WZ). The results of the grey literature search were screened using the same process. All discrepancies between reviewers were resolved by a third reviewer (PR, WZ).
We drafted a data abstraction form with feedback from the Department of Medicine members. Abstracted data included study characteristics (e.g. country of conduct, setting, study design), population characteristics (e.g. type of participant, mean age, % female, expertise), intervention and control characteristics (e.g. description of program, target group, intensity), and types of outcomes (e.g. staff retention, prevalence of unprofessional behaviours, institutional culture). After pilot-testing the data abstraction form on 3 studies, pairs of independent reviewers abstracted the data (RC, SD, VN, PR, WZ); all data were then verified by a third reviewer (RC, PR, WZ).
We did not conduct risk of bias assessment of included articles as per the Joanna Briggs Institute Methods Manual for Scoping Reviews,  which is consistent with scoping reviews on health-related topics .
The synthesis focused on describing approaches used to prevent or manage unprofessional behaviour. We charted the data quantitatively to identify the number of relevant publications according to types of participants, interventions, comparators and outcomes and summarised these findings using descriptive frequencies. We completed a thematic analysis of the definitions for unprofessional behaviour, as we identified many variations used across the studies. Two experienced qualitative analysts (AM, SJ) conducted a familiarization activity by independently listing and naming ideas from the list of definitions. These ideas were then grouped into 4 constructs. Those ideas related to the effects of incivility (e.g., hostile work environment, impact on work performance) and the causes of incivility (e.g., jealousy, taking out dissatisfaction on others) were excluded. The analysts then coded the definitions using the four headings in NVivo 11. Kappa coefficients were calculated to measure agreement in the coding scheme.
We retrieved 12,482 citations from the electronic database search (11,689), grey literature search (299), and reference scanning of relevant systematic reviews (515) (Fig 1). Of these, 130 citations were potentially relevant and their full-texts were reviewed (102 citations from database search, 25 from reference scanning, and 3 from grey literature). Subsequently, 23 articles met our eligibility criteria (17 articles from database search, 5 from reference scanning and 1 from grey literature).
Publication and participant characteristics.
The 23 studies included 12 uncontrolled before and after studies, [33–44] 6 controlled before and after studies, [45–50] 2 cluster-RCTs, [51, 52] 1 RCT,  1 NRCT  and 1 quasi-RCT  (Table 1, S3 Table). Fourteen studies were conducted in the US [34–39, 42, 43, 45, 47, 50, 51, 53, 55], 3 each in Canada [46, 49, 54] and the UK [41, 48, 52], and 1 each in Israel , Spain  and Australia . Four studies reported use of an active comparator [48, 49, 52, 53] while the remainder either had no comparator or a standard practice comparator. Eleven studies (47.8%) were performed in health care organisations [34–37, 40, 42, 43, 45, 49, 50, 54], 5 in education settings (21.7%) [38, 39, 46, 51, 55], 4 in government settings (17.4%) [33, 41, 47, 52] and 3 in private industry (13.0%) [44, 48, 53]. A total of 11,025 participants were included with studies ranging from 16 to 4,032 participants. Of the 11 studies that reported sex of participants, 1% to 96.2% were female [33, 35, 38, 39, 43, 45, 46, 51, 53–55]. Of the 4 studies that reported ethnicity of participants, the majority were Caucasian [35, 45, 53, 55]. The majority of the studies (n = 18 [78%]) targeted staff or line workers, followed by middle managers (n = 10 [43.8%]) [S4 Table].
Most of the studies targeted the individual rather than the organisation. Specifically, 95.7% (n = 22) of studies focused on increasing knowledge and 65.2% (n = 15) on changing behaviour at the individual level; 4 studies (17.4%) focused on individual and organisational changes. A majority of the studies (n = 21, 91.3%) focused the intervention on increasing awareness around unprofessional behaviour (Table 2). A smaller number of studies (n = 8, 34.8%) targeted conflict resolution and assertiveness (n = 4, 17.4%). Of the 7 studies (30.4%) that targeted behaviour change, 4 focused on reducing sexual harassment [33, 51, 53, 55], 1 on reducing verbal harassment , 1 on enhancing communication skills , and 1 on increasing assertiveness and communication skills . The format of the interventions varied; 82.61% (n = 19) of the studies reported using in-person education sessions, and 3% (n = 13.0%) used online or computer-based education sessions. Of the studies that reported the number of educational sessions, a single session was most common (n = 16 studies, 69.6%), while 5 studies (21.7%) reported using multiple sessions.
Seventeen studies (73.9%) reported changes in knowledge of or attitudes towards unprofessional behaviour (Table 1, S5 Table). Fourteen studies (60.9%) reported on the results of incivil behaviour and outcomes of workplace bullying, 2 studies (8.7%) reported on changes in skills to cope with workplace bullying, and 6 studies (26.1%) reported on changes in behaviours related to unprofessional behaviour. Two studies [34, 37] reported on staff retention and both showed increases post-intervention. One of 2 studies that reported absenteeism [52, 54] showed a decrease following the intervention. Of 7 studies that considered perceptions or reports of bullying or harassment, 3 showed increases and 4 showed decreases following the intervention. Four studies [43–45, 52] reported use of a validated outcome measure (S6 Table).
Fifty-seven items were generated from the abstracted definitions of unprofessional behaviour and grouped into four constructs: verbal or non-verbal acts (e.g., vicious words, threats, sexual assault, beating), repeated acts (e.g., persistent negative acts over a period of time), power imbalance (e.g., there is power imbalance between the perpetrator(s) and the victim(s); the victim is unable to defend themselves) and unwelcome behaviour (e.g., unwanted sexual advances, social acts of disrespect or devaluation, gossip, putdowns, sabotaging, blaming, offensive jokes, or coercion). The coding and agreement was found to be good for the qualitative analysis (Kappa coefficients ≥ 0.6). None of the constructs were included in all definitions of unprofessionalism reported in the included manuscripts (Table 3). The most comprehensive definitions for unprofessionalism were those provided in the studies by Kennedy and colleagues  and by Lansbury and colleagues .
We identified 23 studies that described interventions for preventing or managing unprofessional behaviours in a variety of settings. Most of the studies included single component in-person education sessions that targeted individuals, while fewer studies targeted both individuals and institutional culture and most focused on increasing awareness of unprofessional behaviour rather than effecting behaviour change. In studies that assessed the impact of interventions on outcomes such as reports or perceptions of unprofessional behaviour, results were mixed with some showing increases and some decreases following the intervention. These mixed results may be due to increased awareness of the unprofessional behaviour, leading to more comfort in reporting it. Overall, educational interventions may work but they need to be tailored to individual and organisational needs.
The culture of unprofessionalism in academic medicine may be perpetuated through the modelling of abuse that starts in training, thereby normalising the behaviour [19, 56–59]. Our scoping review identified few studies that have targeted academic centres to mitigate this culture. While studies from other fields such as private industry and government may be useful, there are unique aspects of the academic medicine setting that need to be considered when contextualising these interventions. For example, professional hierarchies within medical specialists, the high stress medical environment that includes long work hours and on-call responsibilities, and the physician shortage in certain settings can all exacerbate the risk of unprofessional behaviour [14, 60–62]. Concerns about retaliation may also prohibit reporting of unprofessional behaviour, therefore allowing the behaviour to continue [14, 60–62].
Our scoping review identified a lack of consistency in definitions and terms used for unprofessional behaviour (S1 Fig). Unprofessionalism can include a wide range of behaviours that people perceive as hostile, abusive or humiliating . The lack of agreement on the definitions, terms and behaviours make measuring the behaviour challenging. Thus measuring the impact of strategies to promote professionalism is problematic. Several studies have highlighted the challenge of assessing professionalism and the critical need for further work in this area [63–67].
There are limitations to our scoping review that should be considered. First, our literature search was challenging because of the lack of agreement on the definition and terms used for unprofessional behaviour. As such, our search was broad with >12,000 citations retrieved but we may have missed relevant articles. However, we contacted experts in the field and reviewed references of relevant systematic reviews to facilitate saturation. Second, because this was a scoping review, we did not conduct a risk of bias assessment of the included studies; this could be done in a future, full systematic review.
We believe that the results of this scoping review can be used to target a full systematic review. Given that several relevant studies were identified, this systematic review could focus on studies conducted in health care organisations or educational settings. We also suggest that a realist review could be undertaken that would include the qualitative literature; this would be particularly helpful because of the need to contextualise the effectiveness of interventions. Specifically, a realist review would inform which circumstances and settings a particular intervention would work to mitigate unprofessional behaviour .
This is the first scoping review of strategies to mitigate professional behaviour in workplace settings. It identified where a future systematic review could inform practice in academic medicine and medical education. Most of the studies included single component, in-person education sessions targeting individuals and increasing awareness of unprofessional behaviour. There is limited evidence that printed education materials, and large group education sessions substantially change physician behaviour [69, 70]. Given the need to effect individual behaviour change, strategies to increase awareness are likely not sufficient to address unprofessional behaviour and future primary studies should use behaviour change theory and evidence around what interventions work to effect behaviour change . Moreover, the interventions need to target barriers to professionalism. As fewer studies targeted the institutional culture, this is a critical element to consider in future research.
S2 Table. Workplace bullying definitions, behaviours, and key words.
S4 Table. Individual participant characteristics.
S1 Fig. Word cloud of terms used in definitions of Workplace bullying/incivility.
We thank Dr. Jessie McGowan (JM) for designing the search, Elise Cogo (EC) for peer reviewing the search, Alissa Epworth (AE) for conducting the database search and obtaining full-text articles, Dr. Reena Pattani for her input into the data abstraction form and literature search, and Dr. Gillian Hawker for comments on an earlier version of this manuscript. We thank Theshani De Silva for assistance with preparing the manuscript for publication.
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