Table 2 Themes, sub-themes and illustrative quotes relating to why people do not speak up and unprofessional behaviour continues

Staying silent, but active

Protection of self

“… because the training programs are so difficult to get onto … those tiny, tiny things make a difference. (027)

“I think there's a lot of people that don't go there with people … because they fear for their job.” (009)

“They're only on a year contract. You don't want to ruffle any feathers.” (011)

Justify or excuse behaviour

“He just can't control his temper. … You can forgive people for trying their hardest.” (008)

“We see certain behaviours as … we package it up as them having a bad day, or that’s just part of their personality.” (005)

“I don’t think he can control it. … Again, not because he’s a bad person, but just the way he behaves.” (014)

Emotional reframing

“… she'd just let loose at me in front of everyone in the office. So as soon as she left, they all turned around and were like, ‘You're all right. She's done this before. Don't worry about it.’ That made me feel better that it's not me. It's not me. It's fine.” (027)

“When I heard about that [surgeon being unprofessional towards a new nurse] I was really annoyed. But what I did was, I sent him an email and I said …’I just want to give you some really positive feedback’ … [Since then] he’s been really good. That was two weeks ago.” (017)

N/A – Support Services’ Managers referred to addressing via policies rather than using emotional reframing of situation

Enable with workarounds

N/A – Medical Middle Managers did not refer to workarounds

(Nurses working with a known offender surgeon) “Once they’re pulled out and never have to do his list again, that makes them happy. So, that’s what I do … we roster so that it works out okay.” (017)

“We've recruited people that fit the team a little bit better and there's less of that friction that there was.” (015)

History and hierarchy

Individual, personal experiences

“I don't want to tell anyone because clearly everybody knows this is an issue and just puts up with it. … we just tolerate this behaviour here.” (028)

“The new grads don’t have that resilience yet. But it certainly has an impact. People don’t forget, that’s for sure.” (012)

“Pretty much nothing, just make some decision then after that pretty much stop there. There's no discipline action, no warning as to the issue, etcetera.” (019)

Workplace, organisational culture

You're expected, as a junior doctor, to just deal with it and just—it's like a—what's the word—you've got to develop a thick skin. It's just expected I think.” (007)

“The problem is, these people make so much money for the hospital that—they’ll be spoken to about their behaviour time and time again, but the bottom line is the dollar.” (017)

“There's nothing we can do, that's the thing. This is a culture that's been here since I started. There's just really nothing you can do.” (015)

Double-edged swords

One person makes a big difference (could be a positive or negative impact)

“She just kind of screamed at me and run off. … Then that night I had to work with her again and I was kind of terrified to talk to her at all because she was so scary.” (028)

“Our codirector organised that. It kind of blew my mind. Yeah. He’s like, we want to say what we can do to help … see if we can come up with some solutions. Which I thought was amazing.” (028)

“I know that she [manager] would do something—or she would address it with those people.” (012)

“I haven’t muttered one word to him. So, he’s stayed away from me because he knows that he’s finally—he’s done it twice to me. He knows that he’s broken me.” (017)

“I have a very good direct report. My manager who I've had in and out of my career here, I know that she's available if there's any concerns, or if I need to bounce ideas off her.” (001)

“So, she felt completely disrespected in the situation. My manager was frustrated with her because why didn’t we just provide it? It was just a sandwich. That's how everyone sees it; it's just a sandwich, just give it. But it was breaking the rules and my staff member didn’t feel comfortable doing that.” (015)

Emotional management shifted from one person to another (manager retains issue once issue raised)

“Then I’m just kind of holding it and then I might talk to my boss or kind of keep my ear to the ground or maybe think about how I can raise it in a very de-identified way.” (010)

“Twice, two doctors that were ETHOSed [given an Ethos Reflection message] came to me asking who had ETHOSed them. … I wasn’t supposed to know, and I told them I didn’t know anything about it. It was awful.” (017)

“So normally what we do is we console them,” (018)

Preference for directly addressing (but doing so takes a toll)

“Like that rude registrar, I wasn't going to go out of my way to pick up the phone and call them back and say, you're being really rude. I was a bit shellshocked afterwards.” (029)

“It [complaint] would have come to me and then I would have had to have spoken to the surgeon, who would have probably given me … excuses as to why he was behaving the way he was. Then I probably would have got upset with him because he'd be critical of the staff.” (016)

“So basically what I did, I spoke to the person thinking that that was the right thing to do, then it just tarnished me from then on.” (001)

Confidential and anonymous system (one-sided; only works for reporting not addressing)

“It's really hard because you need the anonymity and at the same time that makes it really hard.” (028)

“You will understand it’s confidential and I won’t be able to tell you what’s been done.” (026)

“The person who puts in the Ethos, they don’t get any feedback, they don’t get anything.” (023)