Speaking up against unsafe unprofessional behaviours: the difficulty in knowing when and how

Authors: Wong BM, Ginsburg S

Reference: BMJ Qual Saf.2017 July;26(11):859-862

Summarised on: 19 April 2018

This editorial focuses on unprofessional behaviour as a potential threat to patient safety. The authors refer to the study by Martinez and colleagues, which found that residents (equivalent for a registrar in New Zealand) reported witnessing unprofessional behaviour more frequently than they observed patient safety breaches (75% vs 46%; p<0.001).

The residents also reported speaking up less frequently about unprofessional behaviour than about traditional safety threats (46% vs 71%; p<0.001). The editorial notes two caveats to the study: it relies on self-reports and what residents perceive as unprofessional may be quite variable; and the urgency of speaking up in the moment may be one reason for the difference in responses.

The authors say that in the past, it may have been possible to separate out professionalism as being ‘soft’ and not necessarily essential to safe patient care. However, emerging evidence shows that this view can no longer be supported. It is possible that aggressive behaviors such as rudeness or intimidation are especially linked to poorer outcomes for patients.

Therefore there is a need to create broad awareness of the link between patient safety and professionalism, and acknowledge that health care providers have a responsibility to mitigate harms associated with unprofessional behaviours.

The authors suggest that the field of patient safety is now shifting away from a ‘no-blame’ culture towards promoting a ‘just culture’, which highlights the need to address both system deficiencies as well as manage individual behavioural choices.

The authors propose a framework to guide speaking-up where unsafe, unprofessional behaviors exists:

  • Is this an example of an unprofessional behavior that could put patient safety at risk?
  • Is there an immediacy to the situation where speaking up in the moment is the optimal approach to mitigate harm or uphold patient safety?
  • What communication approach should be used to express concern?

If a particular unprofessional behaviour poses a risk to patient safety, then the most important consideration relates to the immediacy of the unprofessional behaviour and the likelihood that it puts patient safety at risk. The authors argue for equipping front-line providers with structured approaches to voicing their concerns, and suggest: graded assertiveness frameworks to support communication and team training in patient safety; curriculum changes to teach trainees how to apply communication approaches and to practice their use; faculty development to ensure appropriate role modelling in the clinical learning environment, and regulation. 



We note a recent Health and Disability Commissioner decision, where an anesthetist was found to have breached the Code of Health and Disability Services Consumers’ Rights for failing to ensure the patient had adequate analgesia during an emergency Caesarean section (among other breaches). An obstetrician, also involved, was found to have breached the Code for failing to speak and act with more authority when she thought Mrs A was feeling pain and continuing to operate on the patient. 


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