UNASSIGNED: Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems.
UNASSIGNED: To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them.
UNASSIGNED: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines.
UNASSIGNED: Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022.
UNASSIGNED: Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models.
UNASSIGNED: Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations.
UNASSIGNED: Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues.
UNASSIGNED: This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care.
UNASSIGNED: This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490.
UNASSIGNED: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.
For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a ‘realist review’, which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature – not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour.

UNASSIGNED: The objective of this systematic review was to synthesise literature pertaining to patient and family violence (PFV) directed at Intensive Care Unit (ICU) staff.
UNASSIGNED: Study design was a systematic review. The data was not amenable to meta-analysis.
UNASSIGNED: Electronic searches of databases were conducted to identify studies between 1 January 2000 and 6 March 2023, limited to literature in English only. Published empirical peer-reviewed literature of any design (qualitative or quantitative) were included. Studies which only described workplace violence outside of ICU, systematic reviews, commentaries, editorials, letters, non-English literature and grey literature were excluded. All studies were appraised for quality and risk of bias using validated tools.
UNASSIGNED: Eighteen studies were identified: 13 quantitative; 2 qualitative and 3 mixed methodology. Themes included: (i) what is abuse and what do I do about it? (ii) who is at risk? (iii) it is common, but how common? (iv) workplace factors; (v) impact on patient care; (vi) effect on staff; (vii)the importance of the institutional response; and (viii) current or suggested solutions.
UNASSIGNED: This systematic review demonstrated that PFV in the ICU is neither well-understood nor well-managed due to multiple factors including non-standardised definition of abuse, normalisation, inadequate organisational support and general lack of education of staff and public. This will guide in future research and policy decision making.

In clinical settings, among individuals diagnosed with borderline personality disorder (BPD), typically 75% are female and 25% male, although this discrepancy is not reported in the community. In the literature, little is known of the effectiveness and experiences of treatment of men with BPD. We aimed to review the effectiveness and experiences of treatment for men with BPD and outline future research priorities to promote better recovery. We searched Ovid MEDLINE and PsycINFO for eligible studies from inception until July 29, 2022. Peer-reviewed primary research articles on treatment effectiveness or experience for men with BPD were included. Data from eligible studies were synthesized in a narrative review. The protocol of our review was pre-registered on PROSPERO (CRD42022351908). Seventeen studies met the inclusion criteria, and men with BPD from eight countries were represented. Psychological therapies included Dialectical Behavioral Therapy, Systems Training for Emotional Predictability and Problem Solving, Mentalization Based Therapy, and psychoanalytic therapy. Pharmacologic treatment included topiramate, divalproex Extended-Release, and high-dose baclofen. Five studies investigated the service utilization of men with BPD. Compared to women, men were less likely to access treatment for BPD or find treatment helpful. Our findings demonstrated the potential efficacy of psychotherapy and pharmacologic interventions in reducing anger, aggression, and rule-breaking behavior, with limited evidence for reduction in suicide-related outcomes. Our findings are limited by inadequate power and heterogeneity of the included studies. Further research with larger sample sizes and qualitative studies is needed to better understand the treatment experience for men with BPD.

Cognitive impairment is a core feature of schizophrenia spectrum disorders (SSD). Violent and aggressive behavior represents a complex issue in psychiatry, and people with SSD have been shown to be at risk of being both victims and perpetrators of violence. In this review, the complex relationship between cognitive impairment and violent behavior is explored, also considering the usefulness of treating cognitive impairment to improve violence-related outcomes. Several studies report that cognitive impairment is linked to violent behavior, but significant differences between domains and conflicting results are also present, leaving the identification of specific cognitive profiles predicting violent behavior in SSD as an important aim for future research. Evidence regarding the effectiveness of treating cognitive impairment to improve violent behavior, while heterogeneous, provides more consistent results: cognition-targeting interventions appear to provide significant benefits also in the prevention of aggression in people living with SSD, and preliminary evidence shows cognition-focused interventions targeting violent behavior improve both cognition- and violence-related outcomes. Implementing these interventions in clinical practice could be of great usefulness, particularly in forensic contexts. Physical exercise, which improves cognitive performance and psychosocial functioning in SSD, appears to reduce violent behavior in healthy individuals, but requires further studies in clinical samples.

OBJECTIVE: Despite the critical value of healthcare workers (HCWs) demonstrated during the COVID-19 pandemic, there remains a noted global surge in violence against this population. The present meta-analysis aimed to gather data on the prevalence of workplace violence (WPV) against HCWs and to determine if there is any difference based on gender.
METHODS: This was a systematic review and meta-analysis.
METHODS: A thorough search of PubMed/MEDLINE, Lilacs, and Cochrane Collaboration databases was conducted from the start of the COVID-19 pandemic until March 8, 2023. Two authors independently carried out screening, data extraction, and quality assessment, followed by statistical analysis using random-effects meta-analysis and subgroup analysis to assess heterogeneity.
RESULTS: We included 22 studies with 44,357 participants, of which 79.37% were women. The analysis revealed an overall prevalence of WPV similar in both women (51.86%, 95% confidence interval [CI]: 41.39-62.33) and men (51.45%, 95% CI: 40.95-61.95). There were considerable differences in gender-based WPV across geographic regions. Aggressions tend to be higher toward men in Asia (odds ratio [OR] 0.79, 95% CI 0.74-0.85, P < 0.001). Conversely, in Latin America, WPV prevalence was higher in women (OR 1.20, 95% CI 1.01-1.4, P = 0.035). HCWs from low- middle-income-level countries suffered a higher incidence of violence irrespective of gender compared with high- and upper-middle-income countries (72.36% vs 47.35%).
CONCLUSIONS: Our data indicate that more than half of HCWs experienced WPV during the COVID-19 pandemic. In addition, women and HCWs in low-middle-income countries were notably vulnerable to WPV. A deeper understanding of the nuances behind violence against HCWs will help to facilitate tailored strategies for different demographical contexts.
BACKGROUND: PROSPERO ID: CRD42023403970.

Some patients with autism and severe intellectual disability may experience uncontrolled aggression, causing serious injury or harm to others, and the therapeutic ineffectiveness of traditional pharmacological and behavioral treatment may aggravate symptoms. Deep brain stimulation (DBS) has been tested in patients with little evidence in children and adolescents. Therefore, we analyzed the efficacy and safety of DBS in refractory aggression in pediatric subjects with autism (ASD) and severe intelligence deficit (ID).Methods A meta-analytic review of Web of Science (WOS) and Scopus articles, following Prisma criteria. A total of 555 articles were identified, but after applying the inclusion criteria, only 18 were analyzed. The review of the registries and the extraction of information was performed by 2 independent groups, to reduce the evaluator\'s bias. For the description of the results, pediatric patients with ASD or ID present in each registry, with an application of specialized scales (Overt aggression scale, OAS, and THE modified version of the OAS, MOAS) pre and post-DBS, with a clinical follow-up of at least 12 months, were considered valid. Clinical improvement was calculated using tests of aggressiveness. In each registry with available data and then pooling the means of all patients in the OAS and MOAS, the effect size of DBS (overall and per study) was estimated. Finally, the adapted NOS scale was applied to rate the studies\' quality and level of bias.Results In the studies analyzed, 65/100 were pediatric patients, with a mean age of 16.8 years. Most of the studies were conducted in South America and Europe. In all teams, aggressive behavior was intractable, but only 9 groups (53/65) applied specialized scales to measure aggressiveness, and of these, only 51 subjects had a follow-up of at least 12 months. Thus, in 48/51 a clinical improvement of patients was estimated (94.2%), with a considerable overall effect size (OAS: d = 4.32; MOAS: d = 1.46). However, adverse effects and complications were found in 13/65 subjects undergoing DBS. The brain target with the most evidence and the fewest side effects was the posteromedial hypothalamic nuclei (pHypN). Finally, applying the adapted NOS scale, quality, and bias, only 9 studies show the best indicators.Conclusion An optimal level of efficacy was found in only half of the publications. This is mainly due to design errors and irrelevant information in the reports. We believe that DBS in intractable aggressiveness in children and adolescents with ASD and severe ID can be safe and effective if working groups apply rigorous criteria for patient selection, interdisciplinary assessments, objective scales for aggressiveness, and known surgical targets.

UNASSIGNED: Social rehabilitation of aggression following an Acquired Brain Injury (ABI) is critically important for persons with ABI due to increased vulnerability of criminal behaviour related to post-injury changes in functioning. This review presents findings from studies that evaluated aggression interventions in both community and forensic populations of people with ABI.
UNASSIGNED: We searched PsycINFO, EMBASE, SocINDEX, CINAHL and Medline databases for studies published between 1st January 2000 and 15th October 2023.
UNASSIGNED: There were 15 studies (14 community-based, one forensic) that met inclusion criteria. Pharmacological management (6) was largely ineffective and anger management interventions (6) presented with inconsistent effectiveness. Emotion regulation (1) may be effective for externalised aggression. Both mindfulness and transcranial direct current stimulation (1) were effective, and the results of a forensic peer group approach (1) were not tested for statistical significance. There was variability in the measurement of aggression, injury severity, and cognitive impairment.
UNASSIGNED: Whilst community interventions for aggression in persons with ABI are prevalent, findings for effectiveness have been mixed and there is a paucity of evaluated interventions in forensic samples. Further research is needed to unravel the complex interplay of factors contributing to aggression and develop effective social rehabilitation for persons with ABI.
Social rehabilitation is critical following an Acquired Brain Injury (ABI) due to increased risk of displaying challenging behaviours, such as aggression, that may significantly reduce an individual\'s quality of life.The current review highlights a lack of suitable interventions targeting aggression for individuals with ABI that account for injury-related impairments which impact capacity to engage in intervention.Findings emphasise the need to develop appropriate and relevant social rehabilitation interventions for aggression in ABI populations, particularly forensic populations, to prevent negative outcomes.

Workplace violence (WPV) is a commonly reported occupational hazard in healthcare and its prevalence is increasing. WPV occurs in all types of practice settings, but little is known about WPV in primary care settings in the United States (US). Because primary care practice settings differ from the inpatient settings, further examination of WPV in primary care is warranted. Our objective was to summarize the available literature highlight important gaps. We conducted a search using Pubmed and OVID for US studies of WPV in US-based adult primary care practices. Studies including only pediatric populations were excluded. Due to the lack of available literature conducted in US primary care settings, we expanded our search to include international studies. We identified 70 studies of which 5 were US based. Due to the lack of significant numbers of US-based studies, we opted to conduct a narrative review of all available studies. The evidence shows that WPV is a common occurrence in primary care settings in many countries and that the majority of primary care clinicians have experienced at least some form of non-physical violence in their careers. Most of the studies conducted were cross-sectional in design and reported on both non-physical and physical forms of WPV. There was not a consistent trend between genders in experiencing the major forms of WPV, but women were consistently more likely to be subjected to sexual harassment. Potential root causes for WPV could generally be categorized as patient-level, clinician-level, clinical encounter specific, and operational root causes. While most WPV was found to be non-physical, it still had significant emotional and job-related impacts on clinicians. These troubling results highlight the need for further studies to be conducted in the US.

BACKGROUND: Behavioural emergencies involving aggression in acute care hospitals are increasing globally. Acute care staff are often not trained or confident in their prevention or management. Of available training options simulation-based education is superior for clinical medical education and is gaining acceptance for teaching clinical aggression management skills.
OBJECTIVE: The aim of this study was to conduct a systematic review of the effectiveness of simulation-based education for teaching aggression management skills for health professionals working in acute healthcare settings.
METHODS: The study protocol was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement, registered (27/02/2020) and published. We included randomised controlled trials, non-randomised controlled trials, quasi-experimental studies, and observational studies involving healthcare professionals in acute hospital settings or trainee health professionals who received simulation-based training on managing patient aggression. Comprehensive searches were conducted in PubMed, Ovid MEDLINE, PsycINFO, CINAHL and The Cochrane Library. Two reviewers independently screened all records, extracted data and assessed risk of bias. The primary outcomes included patient outcomes, quality of care, and adverse effects. Secondary outcomes included workplace resource use, healthcare provider related outcomes, knowledge (de-escalation techniques), performance, attitudes, and satisfaction. A narrative synthesis of included studies was performed because substantial variation of interventions and outcome measures precluded meta-analyses.
RESULTS: Twenty-five studies were included with 2790 participants, 2585 (93 %) acute care hospital staff and 205 (7 %) undergraduate university students. Twenty-two studies combined simulation-based education with at least one other training modality. Three studies were randomised controlled trials, one was a pilot and feasibility cluster randomised controlled trial, one was a three-group post-test design and twenty were pre-/post-test design. Twenty-four studies were deemed to be high/critical or serious risk of bias. Four studies collected primary outcome data, all using different methods and with inconsistent findings. Twenty-one studies assessed performance in the test situation, seven studies provided objective ratings of performance and eighteen provided self-report data. Twenty-three studies reported objective or subjective improvements in secondary outcomes.
CONCLUSIONS: Acute healthcare staff who completed simulation-based education on managing clinical aggression showed statistically significant improvements in knowledge and self-reported confidence. However, there is a lack of evidence about the magnitude of these improvements and impact on patient outcomes.
BACKGROUND: PROSPERO Registration Number CRD42020151002.
CONCLUSIONS: Simulation-based education improved acute healthcare clinician knowledge and confidence in managing aggression.

Antisocial behavior in childhood and adolescence is associated with poor family and peer relationships, and a higher risk of mental and physical health problems in adulthood, as well as criminality. Emotions play a central role in children\'s moral development, but most research has focused on negative emotions (e.g., shame and guilt), in relation to childhood antisocial behavior. Research in adult populations indicates that positive emotions experienced in anticipation of, during, and after antisocial acts may play an important role in the development and maintenance of antisocial behavior. Consequently, this systematic review aimed to investigate the relationship between positive emotion and antisocial behavior in children and adolescents. A systematic search in five databases was conducted, yielding 52 studies that used different methodological approaches, samples, designs and methods to examine this association. Results provide support for a positive relationship between positive emotion and antisocial behavior across community, forensic and clinical samples. This link appeared to be stronger for younger children, boys, and for children high in social dominance, callous-unemotional or sensation-seeking traits. Results suggested that positive affect may act in concert with negative emotion, cognitive, personality and motivational processes, as well as peer influences to determine the initiation and maintenance of antisocial behavior. This review presents directions for future research and discusses the implications of findings for prevention and intervention programs for youth with antisocial behavior.