How can interventions more directly address drivers of unprofessional behaviour between healthcare staff?

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.

Navigating the Future of Organisational Health Services Research in Germany and beyond: a Position Paper. / Die Zukunft der organisationalen Versorgungsforschung in Deutschland und darüber hinaus ­ ein Positionspapier.

BACKGROUND: Recent analyses have shown that in health services research in Germany, healthcare organisations are often considered primarily as a study setting, without fully taking their complex organisational nature into account, neither theoretically nor methodologically. Therefore, an initiative was launched to analyse the state of Organisational Health Services Research (OHSR) in Germany and to develop a strategic framework and road map to guide future efforts in the field. This paper summarizes positions that have been jointly developed by consulting experts from the interdisciplinary and international scientific community. METHODS: In July 2023, a scoping workshop over the course of three days was held with 32 (inter)national experts from different research fields centred around OHSR topics using interactive workshop methods. Participants discussed their perspectives on OHSR, analysed current challenges in OHSR in Germany and developed key positions for the field's development. RESULTS: The seven agreed-upon key positions addressed conceptual and strategic aspects. There was consensus that the field required the development of a research agenda that can guide future efforts. On a conceptual level, the need to address challenges in terms of interdisciplinarity, terminology, organisation(s) as research subjects, international comparative research and utilisation of organisational theory was recognized. On a strategic level, requirements with regard to teaching, promotion of interdisciplinary and international collaboration, suitable funding opportunities and participatory research were identified. CONCLUSIONS: This position paper seeks to serve as a framework to support further development of OHSR in Germany and as a guide for researchers and funding organisations on how to move OHSR forward. Some of the challenges discussed for German OHSR are equally present in other countries. Thus, this position paper can be used to initiate fruitful discussions in other countries.

Measuring the overall performance of mental healthcare providers.

To date there have been no attempts to construct composite measures of healthcare provider performance which reflect preferences for health and non-health benefits, as well as costs. Health and non-health benefits matter to patients, healthcare providers and the general public. We develop a novel provider performance measurement framework that combines health gain, non-health benefit, and cost and illustrate it with an application to 54 English mental health providers. We apply estimates from a discrete choice experiment eliciting the UK general population's valuation of non-health benefits relative to health gains, to administrative and patient survey data for years 2013-2015 to calculate equivalent health benefit (eHB) for providers. We measure costs as forgone health and quantify the relative performance of providers in terms of equivalent net health benefit (eNHB): the value of the health and non-health benefits minus the forgone benefit equivalent of cost. We compare rankings of providers by eHB, eNHB, and by the rankings produced by the hospital sector regulator. We find that taking account of the non-health benefits in the eNHB measure makes a substantial difference to the evaluation of provider performance. Our study demonstrates that the provider performance evaluation space can be extended beyond measures of health gain and cost, and that this matters for comparison of providers.

The policy and politics of healthcare corporatisation: The case of the English NHS.

RATIONALE: Few accounts of healthcare corporatisation examine the effects of the 2008 financial crisis. New Politics of the Welfare State (NPWS) theories recognise the relevance of crises but give more attention to programmatic than systemic (structural) retrenchment, and little to healthcare corporatisation. OBJECTIVE: To examine what changes the 2008 financial crisis produced in the pattern of healthcare corporatisation, and the implications for NPWS theories. METHODS: Using administrative data from the English NHS during 1995-2019 we formulated a multi-dimensional index of corporatisation, tested its validity, and used it to analyse longitudinally how the financial crisis affected the balance between the responsibilization of management and re-commodification (introduction of market-like practices) in provider corporatisation. RESULTS: The financial crisis influenced NHS corporatisation through the fiscal austerity with which governments responded. The re-commodification of NHS providers stalled but not the responsibilization of NHS managers. CONCLUSIONS: The corporatisation of NHS providers faltered after the financial crisis. These findings corroborate parts of NPWS theory but also reveal scope for further elaborating its accounts of systemic retrenchment in health systems.

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 .

Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review.

BACKGROUND: Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom. METHODS: This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. RESULTS: Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics. CONCLUSIONS: Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups. 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 .

Modelling the Health Policy Process: One Size Fits All or Horses for Courses?

A range of conceptual models for understanding the policy process have been applied to the health policy process, largely in particular sub areas or policy domains such as public health. However, these contributions appear to offer different rationales and present different frameworks for understanding the policy process. This Editorial critically examines articles that explore the health policy process with models from wider public policy and from health policy. It can be seen that very few of the wider models have been applied in studies of the health policy process. Conversely, some models feature in studies of the health policy process, but not in the wider policy process literature, which suggests that literature on the health policy process is semi-detached from the wider policy process literature. There seem to be two very different future research directions: focusing on 'home grown' models, or taking greater account of the wider policy process literature. Does 'one size fit all' or is it 'horses for courses'?

Towards achieving interorganisational collaboration between health-care providers: a realist evidence synthesis.

Background: Interorganisational collaboration is currently being promoted to improve the performance of NHS providers. However, up to now, there has, to the best of our knowledge, been no systematic attempt to assess the effect of different approaches to collaboration or to understand the mechanisms through which interorganisational collaborations can work in particular contexts. Objectives: Our objectives were to (1) explore the main strands of the literature about interorganisational collaboration and to identify the main theoretical and conceptual frameworks, (2) assess the empirical evidence with regard to how different interorganisational collaborations may (or may not) lead to improved performance and outcomes, (3) understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaborations can best be used to support turnaround processes, (4) develop a typology of interorganisational collaboration that considers different types and scales of collaboration appropriate to NHS provider contexts and (5) generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements. Design: A realist synthesis was carried out to develop, test and refine theories about how interorganisational collaborations work, for whom and in what circumstances. Data sources: Data sources were gathered from peer-reviewed and grey literature, realist interviews with 34 stakeholders and a focus group with patient and public representatives. Review methods: Initial theories and ideas were gathered from scoping reviews that were gleaned and refined through a realist review of the literature. A range of stakeholder interviews and a focus group sought to further refine understandings of what works, for whom and in what circumstances with regard to high-performing interorganisational collaborations. Results: A realist review and synthesis identified key mechanisms, such as trust, faith, confidence and risk tolerance, within the functioning of effective interorganisational collaborations. A stakeholder analysis refined this understanding and, in addition, developed a new programme theory of collaborative performance, with mechanisms related to cultural efficacy, organisational efficiency and technological effectiveness. A series of translatable tools, including a diagnostic survey and a collaboration maturity index, were also developed. Limitations: The breadth of interorganisational collaboration arrangements included made it difficult to make specific recommendations for individual interorganisational collaboration types. The stakeholder analysis focused exclusively on England, UK, where the COVID-19 pandemic posed challenges for fieldwork. Conclusions: Implementing successful interorganisational collaborations is a difficult, complex task that requires significant time, resource and energy to achieve the collaborative functioning that generates performance improvements. A delicate balance of building trust, instilling faith and maintaining confidence is required for high-performing interorganisational collaborations to flourish. Future work: Future research should further refine our theory by incorporating other workforce and user perspectives. Research into digital platforms for interorganisational collaborations and outcome measurement are advocated, along with place-based and cross-sectoral partnerships, as well as regulatory models for overseeing interorganisational collaborations. Study registration: The study is registered as PROSPERO CRD42019149009. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information.

How can the collaboration between health-care providers be improved? There are continuing concerns about poor patient care across the NHS. One of the ways in which governments have tried to solve these issues is by getting services to work together, rather than separately, to solve any problems. The aim of our review is to learn about how, why and when different approaches to working together ­ which we call interorganisational collaboration ­ can be used to improve the performance of NHS providers. We reviewed published evidence and carried out interviews with NHS staff. We also carried out interviews and a focus group with patient and public representatives. Our review finds that interorganisational collaborations can work well when a series of elements are in place, which includes the need to build trust between everyone involved. Having a belief in the collaboration is also needed to help inspire others to get involved. To try and reduce possible problems, setting priorities and having clear methods to show how improvements can be achieved are important, as well as having an agreed contract in place to ensure that any conflicts are resolved. If done well, collaboration can improve resource allocation, coordination, communication and shared learning about best practice. Our review provides valuable evidence of how different approaches to interorganisational collaboration can be used by NHS providers to work together to improve services in different situations. Our review provides different options for organisations to reflect on how well they are collaborating, which includes the involvement of key stakeholders, such as patients, the public and communities.

The impact of vulnerability and exposure to pervasive interprofessional incivility among medical staff on wellbeing.

Introduction: Traditional methods for modelling human interactions within organisational contexts are often hindered by the complexity inherent within these systems. Building on new approaches to information modelling in the social sciences and drawing on the work of scholars in transdisciplinary fields, we proposed that a reliable model of human interaction as well as its emergent properties can be demonstrated using theories related to emergent information. Methods: We demonstrated these dynamics through a test case related to data from a prevalence survey of incivility among medical staff. For each survey respondent we defined their vulnerability profile based upon a combination of their biographical characteristics, such as age, gender, and length of employment within a hospital and the hospital type (private or public). We modelled the interactions between the composite vulnerability profile of staff against their reports of their exposure to incivility and the consequent negative impact on their wellbeing. Results: We found that vulnerability profile appeared to be proportionally related to the extent to which they were exposed to rudeness in the workplace and to a negative impact on subjective wellbeing. Discussion: This model can potentially be used to tailor resources to improve the wellbeing of hospital medical staff at increased risk of facing incivility, bullying and harassment at their workplaces.

Organizational resilience in healthcare: a review and descriptive narrative synthesis of approaches to resilience measurement and assessment in empirical studies.

BACKGROUND: The coronavirus pandemic has had a profound impact on organization and delivery of care. The challenges faced by healthcare organizations in dealing with the pandemic have intensified interest in the concept of resilience. While effort has gone into conceptualising resilience, there has been relatively little work on how to evaluate organizational resilience. This paper reports on an extensive review of approaches to resilience measurement and assessment in empirical healthcare studies, and examines their usefulness for researchers, policymakers and healthcare managers. METHODS: Various databases (MEDLINE, EMBASE, PsycINFO, CINAHL (EBSCO host), Cochrane CENTRAL (Wiley), CDSR, Science Citation Index, and Social Science Citation Index) were searched from January 2000 to September 2021. We included quantitative, qualitative and modelling studies that focused on measuring or qualitatively assessing organizational resilience in a healthcare context. All studies were screened based on titles, abstracts and full text. For each approach, information on the format of measurement or assessment, method of data collection and analysis, and other relevant information were extracted. We classified the approaches to organizational resilience into five thematic areas of contrast: (1) type of shock; (2) stage of resilience; (3) included characteristics or indicators; (4) nature of output; and (5) purpose. The approaches were summarised narratively within these thematic areas. RESULTS: Thirty-five studies met the inclusion criteria. We identified a lack of consensus on how to evaluate organizational resilience in healthcare, what should be measured or assessed and when, and using what resilience characteristic and indicators. The measurement and assessment approaches varied in scope, format, content and purpose. Approaches varied in terms of whether they were prospective (resilience pre-shock) or retrospective (during or post-shock), and the extent to which they addressed a pre-defined and shock-specific set of characteristics and indicators. CONCLUSION: A range of approaches with differing characteristics and indicators has been developed to evaluate organizational resilience in healthcare, and may be of value to researchers, policymakers and healthcare managers. The choice of an approach to use in practice should be determined by the type of shock, the purpose of the evaluation, the intended use of results, and the availability of data and resources.

Organisational drivers of performance in mental health providers.

PURPOSE: This study aims to compare and contrast the core organisational processes across high and low performing mental health providers in the English National Health Service (NHS). DESIGN/METHODOLOGY/APPROACH: A multiple case study qualitative design incorporating a full sample of low and high performing mental health providers. FINDINGS: This study suggests that the organisational approaches used to govern and manage mental health providers are associated with their performance, and the study's findings give clues as to what areas might need attention. They include, but are not limited to: developing appropriate governance frameworks and organisational cultures, ensuring that staff across the organisation feel "psychologically safe" and able to speak up when they see things that are going wrong; a focus on enhancing quality of services rather than prioritising cost-reduction; investing in new technology and digital applications; and nurturing positive inter-organisational relationships across the local health economy. ORIGINALITY/VALUE: Highlights considerable divergence in organisation and management practices that are associated with the performance of mental health trusts in the English NHS.

Impact of COVID-19 in mental health trusts.

OBJECTIVE: To explore how mental health trusts in England adapted and responded to the challenges posed by the COVID-19 pandemic, with the aim of identifying lessons that can be learned during and beyond the pandemic. METHODS: Following a scoping study, we undertook 52 semi-structured interviews with senior managers, clinicians, patient representatives and commissioning staff across four case study sites. These sites varied in size, location and grading awarded by a national regulatory body. We explored how services have been repurposed and reorganized in response to the pandemic and the participants' perceptions of the impact of these changes on quality of care and the wellbeing of staff. RESULTS: Mental health trusts have shown great flexibility and resilience in rapidly implementing new models of care and developing creative digital solutions at speed. New collaborative arrangements have been stimulated by a shared sense of urgency and enabled by additional funding and a more permissive policy environment. But there has also been a significant negative impact on the wellbeing of staff, particularly those staff from a minority ethnic background. Also, there were concerns that digital technology could effectively disenfranchise some vulnerable groups and exacerbate existing health inequalities. CONCLUSIONS: Many of the service changes and digital innovations undertaken during the pandemic appear promising. Nevertheless, those changes need to be urgently and rigorously appraised to assure their effectiveness and to assess their impact on social exclusion and health inequalities.

IT and the Quality and Efficiency of Mental Health Care in a Time of COVID-19: Case Study of Mental Health Providers in England.

BACKGROUND: In England, COVID-19 has significantly affected mental health care and tested the resilience of health care providers. In many areas, the increased use of IT has enabled traditional modes of service delivery to be supported or even replaced by remote forms of provision. OBJECTIVE: This study aimed to assess the use and impact of IT, in remote service provision, on the quality and efficiency of mental health care during the pandemic. We drew on sociotechnical systems theory as a conceptual framework to help structure the gathering, analysis, and interpretation of data. METHODS: We conducted a national scoping survey that involved documentary analysis and semistructured interviews with 6 national stakeholders and case studies of 4 purposefully selected mental health providers in England involving interviews with 53 staff members. RESULTS: Following the outbreak of COVID-19, mental health providers rapidly adjusted their traditional forms of service delivery, switching to digital and telephone consultations for most services. The informants provided nuanced perspectives on the impact on the quality and efficiency of remote service delivery during the pandemic. Notably, it has allowed providers to attend to as many patients as possible in the face of COVID-19 restrictions, to the convenience of both patients and staff. Among its negative effects are concerns about the unsuitability of remote consultation for some people with mental health conditions and the potential to widen the digital divide and exacerbate existing inequalities. Sociotechnical systems theory was found to be a suitable framework for understanding the range of systemic and sociotechnical factors that influence the use of technology in mental health care delivery in times of crisis and normalcy. CONCLUSIONS: Although the use of IT has boosted mental health care delivery during the pandemic, it has had mixed effects on quality and efficiency. In general, patients have benefited from the convenience of remote consultation when face-to-face contact was impossible. In contrast, patient choice was often compromised, and patient experience and outcomes might have been affected for some people with mental health conditions for which remote consultation is less suitable. However, the full impact of IT on the quality and efficiency of mental health care provision along with the systemic and sociotechnical determinants requires more sustained and longitudinal research.

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals.

PURPOSE: The study aimed to understand the significance of how employee personhood and the act of speaking up is shaped by factors such as employees' professional status, length of employment within their hospital sites, age, gender and their ongoing exposure to unprofessional behaviours. DESIGN/METHODOLOGY/APPROACH: Responses to a survey by 4,851 staff across seven sites within a hospital network in Australia were analysed to interrogate whether speaking up by hospital employees is influenced by employees' symbolic capital and situated subjecthood (SS). The authors utilised a Bourdieusian lens to interrogate the relationship between the symbolic capital afforded to employees as a function of their professional, personal and psycho-social resources and their self-reported capacity to speak up. FINDINGS: The findings indicate that employee speaking up behaviours appear to be influenced profoundly by whether they feel empowered or disempowered by ongoing and pre-existing personal and interpersonal factors such as their functional roles, work-based peer and supervisory support and ongoing exposure to discriminatory behaviours. ORIGINALITY/VALUE: The findings from this interdisciplinary study provide empirical insights around why culture change interventions within healthcare organisations may be successful in certain contexts for certain staff groups and fail within others.

Why do acute healthcare staff engage in unprofessional behaviours towards each other and how can these behaviours be reduced? A realist review protocol.

INTRODUCTION: Unprofessional behaviours encompass many behaviours including bullying, harassment and microaggressions. These behaviours between healthcare staff are problematic; they affect people's ability to work, to feel psychologically safe at work and speak up and to deliver safe care to patients. Almost a fifth of UK National Health Service staff experience unprofessional behaviours in the workplace, with higher incidence in acute care settings and for staff from minority backgrounds. Existing analyses have investigated the effectiveness of strategies to reduce these behaviours. We seek to go beyond these, to understand the range and causes of such behaviours, their negative effects and how mitigation strategies may work, in which contexts and for whom. METHODS AND ANALYSIS: This study uses a realist review methodology with stakeholder input comprising a number of iterative steps: (1) formulating initial programme theories drawing on informal literature searches and literature already known to the study team, (2) performing systematic and purposive searches for grey and peer-reviewed literature on Embase, CINAHL and MEDLINE databases as well as Google and Google Scholar, (3) selecting appropriate documents while considering rigour and relevance, (4) extracting data, (5) and synthesising and (6) refining the programme theories by testing the theories against the newly identified literature. ETHICS AND DISSEMINATION: Ethical review is not required as this study is a secondary research. An impact strategy has been developed which includes working closely with key stakeholders throughout the project. Step 7 of our project will develop pragmatic resources for managers and professionals, tailoring contextually-sensitive strategies to reduce unprofessional behaviours, identifying what works for which groups. We will be guided by the 'Evidence Integration Triangle' to implement the best strategies to reduce unprofessional behaviours in given contexts. Dissemination will occur through presentation at conferences, innovative methods (cartoons, videos, animations and/or interactive performances) and peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42021255490.