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.

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

BACKGROUND: The critical role that middle managers play in enacting organisational culture change designed to address unprofessional co-worker behaviours has gone largely unexplored. We aimed to explore middle managers' perspectives on i) whether they speak up when they or their team members experience unprofessional behaviours (UBs); ii) how concerns are handled; iii) the outcomes; and iv) the role of a professional accountability culture change program (known as Ethos) in driving change. METHODS: Qualitative, constructivist approach. Five metropolitan hospitals in Australia which had implemented Ethos. Purposive sampling was used to invite middle-level managers from medicine, nursing, and non-clinical support services. Semi-structured interviews conducted remotely. Inductive, reflexive thematic and descriptive thematic analyses undertaken using NVivo. RESULTS: Thirty interviews (approximately 60 min; August 2020 to May 2021): Nursing (n = 12), Support Services (n = 10), and Medical (n = 8) staff, working in public (n = 18) and private (n = 12) hospitals. One-third (n = 10) had a formal role in Ethos. All middle managers (hearers) had experienced the raising of UBs by their team (speakers). Themes representing reasons for ongoing UBs were: staying silent but active; history and hierarchy; and double-edged swords. The Ethos program was valued as a confidential, informal, non-punitive system but required improvements in profile and effectiveness. Participants described four response stages: i) determining if reports were genuine; ii) taking action depending on the speaker's preference, behaviour factors (type, frequency, impact), if the person was known/unknown; iii) exploring for additional information; and iv) addressing either indirectly (e.g., change rosters) or directly (e.g., become a speaker). CONCLUSIONS: Addressing UBs requires an organisational-level approach beyond supporting staff to speak up, to include those hearing and addressing UBs. We propose a new hearer's model that details middle managers' processes after a concern is raised, identifying where action can be taken to minimise avoidant behaviours to improve hospital culture, staff and patient safety.

Professional Accountability of Caring for Patients with COVID-19: A Phenomenographic Study.

The purpose of this study was to explore nurses' care experiences for COVID-19 patients during the pandemic in Taiwan. The qualitative approach of phenomenography was used. Thirty-four nurses were recruited from two assigned hospitals in which COVID-19 patients were treated in Taiwan from July to May 2021. The method of data collection in the study involved a semi-structured interview and drawing. Interviews were audio-recorded and transcribed verbatim. Phenomenographic analysis was used to analyze the qualitative data. Four categories of description of experiences of caring for COVID-19 patients were identified: facing uncountable stresses from all sides, strict implementation of infection control interventions to provide safe care, confronting ethical dilemmas and making difficult decisions, and reflecting on the meaning of care in nursing. Professional accountability was the core theme found to represent the central meaning of nurses caring for COVID-19 patients. Nurses were under enormous stress while caring for COVID-19 patients during the pandemic and were negatively affected physically, psychologically, and socially. Professional accountability in caring for COVID-19 patients can be enhanced through adequate support from nursing managers and by in-service training designed to update knowledge and skills related to infection control intervention.

Retrospective analysis of factors influencing the implementation of a program to address unprofessional behaviour and improve culture in Australian hospitals.

BACKGROUND: Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. METHOD: Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. RESULTS: Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool ('Design quality and packaging'), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos ('Goals and Feedback', 'Access to Knowledge and Information'). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. CONCLUSION: Aspects of the inner setting (e.g., 'Leadership Engagement', 'Tension for Change') had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

Evidence-informed practice: simplifying and applying the concept for nursing students and academics.

BACKGROUND: Nurses' ability to apply evidence effectively in practice is a critical factor in delivering high-quality patient care. Evidence-based practice (EBP) is recognised as the gold standard for the delivery of safe and effective person-centred care. However, decades following its inception, nurses continue to encounter difficulties in implementing EBP and, although models for its implementation offer stepwise approaches, factors, such as the context of care and its mechanistic nature, act as barriers to effective and consistent implementation. It is, therefore, imperative to find a solution to the way evidence is applied in practice. Evidence-informed practice (EIP) has been mooted as an alternative to EBP, prompting debate as to which approach better enables the transfer of evidence into practice. Although there are several EBP models and educational interventions, research on the concept of EIP is limited. This article seeks to clarify the concept of EIP and provide an integrated systems-based model of EIP for the application of evidence in clinical nursing practice, by presenting the systems and processes of the EIP model. Two scenarios are used to demonstrate the factors and elements of the EIP model and define how it facilitates the application of evidence to practice. The EIP model provides a framework to deliver clinically effective care, and the ability to justify the processes used and the service provided by referring to reliable evidence.

The Goldwater Rule: a bastion of a bygone era?

In tandem with the changing political landscape in recent years, interest in the Goldwater Rule has re-emerged within psychiatric discourse. Initiated in 1973, the Goldwater Rule is an ethical code specific to psychiatry created by the American Psychiatric Association in response to events surrounding the USA presidential election of 1964, in which the integrity of the psychiatric profession was challenged. Current detractors view the rule as an antiquated entity which obfuscates psychiatric pragmatism and progression. Proponents underscore its role in maintaining both respectful objectivity and diagnostic integrity within the psychiatric assessment process. This essay aims to explore the origin of the rule, and critique its applicability to modern-day psychiatric practice.

A hermeneutical study of professional accountability in nursing.

AIMS AND OBJECTIVES: This paper presents findings from a hermeneutical study which sought to explore how registered nurses experienced and perceived their professional accountability in clinical settings. BACKGROUND: Professional accountability encompasses the ideals and standards of nursing practice. Nurses are accountable for their actions under civil, criminal and contract law to their; employing organisation, their regulatory body and the patients for whom they care. DESIGN: This paper reports on a Heideggerian hermeneutical study involving seven registered nurses, working in clinical practice in the National Health Service in the United Kingdom. Methods The study adopted purposive sampling, collecting data by means of in-depth interviews. Data were analysed using the hermeneutic circle. COREQ checklist was used as a reporting guideline for this study. RESULTS: The findings suggest that professional accountability in nursing practice is a complex phenomenon, which can be compromised by many factors which are historically, socially or politically driven Participants experienced challenges through a lack of resources and poor managerial support, which compromised their ability to deliver high-quality patient care. However, collegiality strongly impacted upon resilience and positively influenced their well-being. RELEVANCE TO CLINICAL PRACTICE: Amid the challenges of the clinical workplace, a positive workplace culture with visible managerial support is a fundamental requirement in supporting professional accountability, development and retention of nurses. Findings highlight the view that leadership should be seen as a collective responsibility, which empowers staff to positively change the practice environment.

Poor care and the professional duty of the registered nurse.

Concerns have been raised in recent years about standards of care in the UK. Notable failures have been identified in the care of vulnerable older adults. This article identifies and discusses some logical steps which might be taken to minimise the risk of individual and systemic care failure in settings for older adults. These steps include frank discussion about ageism to promote empowerment and respect for older people; ensuring robust policies are in place that support and encourage the reporting of poor care; and ensuring that registered practitioners are aware of their accountability for their actions and also their omissions should they witness poor care. In addition to reducing the risk of poor care, these steps could contribute to having a more confident, competent and empowered workforce.

International perspectives on social media guidance for nurses: a content analysis.

Aim This article reports the results of an analysis of the content of national and international professional guidance on social media for the nursing profession. The aim was to consolidate good practice examples of social media guidelines, and inform the development of comprehensive guidance. Method A scoping search of professional nursing bodies' and organisations' social media guidance documents was undertaken using google search. Results 34 guidance documents were located, and a content analysis of these was conducted. Conclusion The results, combined with a review of competency hearings and literature, indicate that guidance should cover the context of social media, and support nurses to navigate and negotiate the differences between the real and online domains to help them translate awareness into actions.

Restructuring supervision and reconfiguration of skill mix in community pharmacy: Classification of perceived safety and risk.

BACKGROUND: Broadening the range of services provided through community pharmacy increases workloads for pharmacists that could be alleviated by reconfiguring roles within the pharmacy team. OBJECTIVES: To examine pharmacists' and pharmacy technicians (PTs)' perceptions of how safe it would be for support staff to undertake a range of pharmacy activities during a pharmacist's absence. Views on supervision, support staff roles, competency and responsibility were also sought. METHODS: Informed by nominal group discussions, a questionnaire was developed and distributed to a random sample of 1500 pharmacists and 1500 PTs registered in England. Whilst focused on community pharmacy practice, hospital pharmacy respondents were included, as more advanced skill mix models may provide valuable insights. Respondents were asked to rank a list of 22 pharmacy activities in terms of perceived risk and safety of these activities being performed by support staff during a pharmacist's absence. Descriptive and comparative statistic analyses were conducted. RESULTS: Six-hundred-and-forty-two pharmacists (43.2%) and 854 PTs (57.3%) responded; the majority worked in community pharmacy. Dependent on agreement levels with perceived safety, from community pharmacists and PTs, and hospital pharmacists and PTs, the 22 activities were grouped into 'safe' (n = 7), 'borderline' (n = 9) and 'unsafe' (n = 6). Activities such as assembly and labeling were considered 'safe,' clinical activities were considered 'unsafe.' There were clear differences between pharmacists and PTs, and sectors (community pharmacy vs. hospital). Community pharmacists were most cautious (particularly mobile and portfolio pharmacists) about which activities they felt support staff could safely perform; PTs in both sectors felt significantly more confident performing particularly technical activities than pharmacists. CONCLUSION: This paper presents novel empirical evidence informing the categorization of pharmacy activities into 'safe,' 'borderline' or 'unsafe.' 'Borderline' activities will deserve particular attention, especially where they are part of processes, e.g. dispensing. This categorization could help inform reconfiguration of skill mix in community pharmacy and thus make an important contribution to the rebalancing medicines legislation agenda and pharmacist supervision.

Defining professional nursing accountability: a literature review.

Professional nursing accountability is described by both professional nursing organizations and nursing education credentialing agencies as a core aspect that underpins professional nursing practice. Although accountability is foundational to professional practice, a review of the literature revealed no consistent language or definition regarding professional nursing accountability. Instead, the literature itself reveals that professional nursing accountability is challenging to both describe and define. The ambiguity surrounding how to define professional nursing accountability contributes to challenges associated with both teaching and evaluating student nurse accountability within nursing education curricula. This article provides a reliable and comprehensive definition of professional nursing accountability derived from a synthesis of the literature. Recommendations for nursing education practice and recommendations for nursing education research are proposed.