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“Bad apples” study shows British doctors’ discipline is lighter than nurses’

Physicians charged with sexual misconduct and other breaches of professional ethics in the United Kingdom emerge with markedly lighter discipline than nurses charged with similar behavior, a new study funded by the British Professional Standards Authority finds.

Released in November, the study analyzed 6,714 “fitness to practice” cases involving doctors, nurses and midwives, and allied health professionals. The most prevalent type of conduct for all three groups related to dishonesty, the authors found, while the frequency and type of sexual misconduct—and punishments for it—varied depending on the group. The study is titled “Bad Apples? Bad Barrels? or Bad Cellars?” and sub-headed “Antecedents and Processes of Professional Misconduct in UK Health and Social Care: Insights into sexual misconduct and dishonesty.”

One of the study’s most striking findings is that fitness-to-practice cases of UK physicians were much more likely to involve sexual misconduct, but proportionately, nurses charged with sexual misconduct were much more likely to be disciplined harshly. Nurses commonly would be struck off the registers, while doctors were more likely to be suspended or cautioned.

Differences in the type of sexual misconduct could explain part of this phenomenon, the authors speculate. “Preliminary analysis suggests that nurses’ cases are perhaps more clear-cut and explicit,” often involving groping or sexual relations with patients outside the workplace.

“Doctors, on the other hand, often involved incidents which are arguably more complex, with consensual relationships developing between doctors and their patients more slowly over time, or where patient abuse was clouded by patient doubt over the appropriateness of consultations, which is more difficult and lengthy for panels to investigate.”

The authors cite three ways in which professional misconduct is generally analyzed: 1) As individual behavior, seen as atypical and perpetrated by outliers (“bad apples”); 2) Through social learning theory which highlights the role of social contexts in the creation and perpetuation of deviant norms (“bad barrels”); and 3) Through ecosystem theory looking at broader demographic and cultural attributes to explain behavior (“bad cellars”).

Dishonesty and theft were charged in 1,784 cases, with doctors, nurses/midwives, and allied health professionals all having roughly the same percentages of misconducts in this category.

But among allied health professionals, dishonesty/theft is accompanied by actual criminal convictions and drug-related charges. Among doctors and nurses, theft is more likely to be associated with production deviance charges such as poor recordkeeping, failure to follow regulatory requirements, substandard care, or poor communication.

As with sexual misconduct, dishonesty by doctors was treated less harshly (e.g. through warnings) than dishonesty by nurses/midwives (e.g., through disciplinary sanctions). The study contrasted the forgiving tone of discussions of doctors’ dishonest conduct with the more severe accounts of nurses’ dishonest conduct.

The authors urge greater attention to the collective dimensions of professional wrongdoing (“bad cellars”), including “the role of group norms, the perverse efforts of some to obtain more power, and the impact of stress and strain from coping with resource pressures. All of these all play a part in creating environments which can facilitate or even trigger misconducts.”

More effective and consistent control systems (discipline programs) in detecting and deterring perpetrators are needed, the authors stress. Fewer discrepancies in the charges recorded and the sanctions applied for doctors versus nurses/midwives and allied health practitioners would increase the trustworthiness of those control systems.

Better reporting and categorization of discipline cases would also allow more support for ongoing analysis of professional misconduct and improve ongoing understanding of how and why misconduct occurs, the study concludes.