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Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review
  1. Linda Guo1,2,
  2. Benjamin Ryan3,
  3. Isabel Anne Leditschke1,4,
  4. Kimberley J Haines5,6,
  5. Katrina Cook7,
  6. Lars Eriksson8,
  7. Olusegun Olusanya9,
  8. Tanya Selak10,11,
  9. Kiran Shekar2,12,
  10. Mahesh Ramanan2,7,12,13
  1. 1Adult Intensive Care Services, Mater Health Services Brisbane, Brisbane, Queensland, Australia
  2. 2School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
  3. 3Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
  4. 4Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
  5. 5Department of Physiotherapy, Western Health, Footscray, Victoria, Australia
  6. 6Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
  7. 7Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
  8. 8The University of Queensland Library, The University of Queensland, Brisbane, Queensland, Australia
  9. 9Intensive Care Unit, The Royal London Hospital, London, UK
  10. 10Department of Anaesthesia, Wollongong Hospital, Wollongong, New South Wales, Australia
  11. 11School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
  12. 12Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
  13. 13Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
  1. Correspondence to Dr Linda Guo, Adult Intensive Care Services, Mater Health Services Brisbane, South Brisbane 4101, Queensland, Australia; linda.guo{at}


Background Recent studies suggest that displays of unacceptable behaviour, including bullying, discrimination and harassment, between healthcare workers (HCWs) may impair job performance, and in turn, increase the frequency of medical errors, adverse events and healthcare-related complications. The objective of this systematic review was to summarise the current evidence of the impact of unacceptable behaviour occurring between HCWs on clinical performance and patient outcomes.

Methods We searched MEDLINE, Embase, PsycINFO and CINAHL from 1 January 1990 to 31 March 2021. The search results were screened by two independent reviewers and studies were included if they were original research that assessed the effects of unacceptable behaviour on clinical performance, quality of care, workplace productivity or patient outcomes. Risk of bias was assessed using tools relevant to the study design and the data were synthesised without meta-analysis.

Results From the 2559 screened studies, 36 studies were included: 22 survey-based studies, 4 qualitative studies, 3 mixed-methods studies, 4 simulation-based randomised controlled trials (RCTs) and 3 other study designs. Most survey-based studies were low quality and demonstrated that HCWs perceived a relationship between unacceptable behaviour and worse clinical performance and patient outcomes. This was supported by a smaller number of higher quality retrospective studies and RCTs. Two of four RCTs produced negative results, possibly reflecting inadequate power or study design limitations. No study demonstrated any beneficial effect of unacceptable behaviour on the study outcomes.

Conclusions Despite the mixed quality of evidence and some inconsistencies in the strengths of associations reported, the overall weight of evidence shows that unacceptable behaviour negatively affects the clinical performance of HCWs, quality of care, workplace productivity and patient outcomes. Future research should focus on the evaluation and implementation of interventions that reduce the frequency of these behaviours.

  • communication
  • diagnostic errors
  • human factors
  • patient safety
  • teamwork

Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplemental information.

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  • Contributors The study was overseen by MR. LE performed the search. LG and BR performed the study screening, data extraction and quality assessment. All authors contributed to, read, provided feedback on and approved the final manuscript. LG is the study guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

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

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