Characteristics, Predictors and Reasons for Regulatory Body Disciplinary Action in Health Care: A Scoping Review

  • Journal of Medical Regulation
  • December 2021,
  • 107
  • (4)
  • 17-31;
  • DOI: https://doi.org/10.30770/2572-1852-107.4.17

ABSTRACT

What research has been done to characterize the outcomes of disciplinary action or fitness-to-practice cases for regulated health professionals?

To answer this research question, relevant publications were identified in PubMed, Ovid EMBASE, CINAHL via EBSCOhost, and Scopus. Included papers focused on reviews of regulatory body disciplinary action for regulated health professionals.

Of 108 papers that were included, 84 studied reasons for discipline, 68 studied penalties applied, and 89 studied characteristics/predictors of discipline. Most were observational studies that used administrative data such as regulatory body discipline cases. Studies were published between 1990–2020, with two-thirds published from 2010–2020. Most research has focused on physicians (64%), nurses (10%), multiple health professionals (8.3%), dentists (6.5%) and pharmacists (5.5%). Most research has originated from the United States (53%), United Kingdom (16%), Australia (9.2%), and Canada (6.5%). Characteristics that were reviewed included: gender, age, years in practice, practice specialty, license type/profession, previous disciplinary action, board certification, and performance on licensing examinations.

As most research has focused on physicians and has originated from the United States, more research on other professions and jurisdictions is needed. Lack of standardization in disciplinary processes and definitions used to categorize reasons for discipline is a barrier to comparison across jurisdictions and professions. Future research on characteristics and predictors should be used to improve equity, support practitioners, and decrease disciplinary action.

Introduction

In order to protect the public and ensure safe and quality care, health professionals are usually regulated by the government or through self-regulation, where the government has given the profession the responsibility to regulate themselves.1,2 Forms of regulation vary across jurisdictions, but typically regulatory bodies register and license health professionals and set standards of practice.2–4 Regulatory bodies also handle complaints and concerns about clinical incompetence or professionalism, where the highest level of sanctioning at the regulatory body level is through the disciplinary action process. While administrative databases of disciplinary action cases provide a wealth of information, it is unclear what research has been conducted about disciplinary action cases.

This review was conducted to describe and characterize research on regulatory body disciplinary action for health professionals, specifically reasons for disciplinary action, penalties applied, and characteristics of health professionals subject to disciplinary action. Our original research question was: What research has been done on disciplinary action or fitness-to-practice proceedings for regulated health professionals? However, we found that a large number of publications that fit our inclusion criteria focused on socio-legal aspects of health professional regulation, such as policy and disciplinary action processes or critiques of fitness-to-practice processes.5–11 Thus, we narrowed our research question to: What research has been done to characterize the outcomes of disciplinary action or fitness-to-practice cases for regulated health professionals?

Methods

The framework proposed by Arksey and O’Malley was used for this scoping review.12 A systematic review searches the literature for the research on a specific, well-defined question, typically including only studies with a specific research design or quality. In contrast, a scoping review uses a broader lens to identify research that has been conducted in a particular area, which can be valuable to identify gaps in literature, to assess the value of conducting a full systematic review, and to summarize research across multiple types of study designs. Original research papers or review articles in English were included if they focused on reviews of regulatory body disciplinary action cases for health professionals to determine reasons for disciplinary action, penalties applied, predictors of disciplinary action or characteristics of professionals that are subject to disciplinary action. Qualitative research and publications related to socio-legal analyses such as the implications of policy on the disciplinary action process were excluded. Papers were excluded if they focused on disciplinary action for unregulated health professionals (e.g., personal support workers) or veterinarians, if the disciplinary action was not administered by the regulatory body (e.g., organizational disciplinary action or legal malpractice cases), or if the publication was a report of a regulatory body disciplinary case. Papers con cerning regulatory body practices related to maintenance of competence or quality assurance were excluded in order to focus on research related to disciplinary action.

Relevant articles were identified in PubMed (1950–present), Ovid EMBASE (1980–present), CINAHL via EBSCOhost (1982–present) and Scopus (1966–present). These databases were chosen to capture relevant articles in medicine and allied health. Search strategies were drafted by an experienced librarian and a researcher, and the final searches were conducted on June 5, 2020. The search strategies were comprised of subject headings (MeSH) and keywords related to “healthcare professionals” and “disciplinary action.” Search terms were gathered by reviewing the vocabulary of select relevant articles, as well as database thesauri. As an example, the final PubMed search strategy is included in Appendix A.

Database results were imported directly into Covidence (Veritas Health Innovation, Melbourne, Australia). Duplicates were identified and removed by the software, and one researcher reviewed the duplicates for accuracy. Articles were also manually screened for duplicates. Screening was conducted independently by two researchers and occurred in two stages — title and abstract, and full-text. At each stage, disagreements were resolved by discussion and agreement was calculated using Cohen’s Kappa.

A data extraction form using Google Forms was drafted (Appendix B). To refine the data extraction form, two researchers independently extracted data from 20 full-text articles, with discussion and refinement occurring after 10 cases and again after 20 cases. Data extraction for the remaining cases was conducted independently, with comparison and consensus occurring at the end. Data was organized using Microsoft Excel (Version 16.43). We grouped studies by type of health professional, and summarized the reasons for discipline, characteristics of those disciplined, and study design.

Results

A total of 4,153 studies were obtained after searching the databases. After removing duplicates, 3,188 articles were screened at the title and abstract stage and 312 articles were screened at the full-text stage. We included 108 studies in the final extraction and analysis (Figure 1).13–120 Using Cohen’s Kappa, inter-rater reliability for the title and abstract screening was calculated to be 0.564, indicating moderate agreement, and for the full-text screening stage was calculated to be 0.757, indicating substantial agreement.121

PRISMA Flow Diagram of Included Studies
Figure 1.

PRISMA Flow Diagram of Included Studies

Characteristics and key findings of each study are described in Appendix C.* Studies were published between 1990 to 2020, with 67% of studies (72/108) published from 2010 to 2020 (Figure 2). Most available research has been conducted in the USA (n=57, 53%), followed by the United Kingdom (n=17, 16%), Australia (n=10, 9.3%), Canada (n=7, 6.5%), and Denmark (n=4, 3.7%). Most publications focused on medicine (n=69, 64%), followed by nursing (n=11, 10%), multiple health professions (n=9, 8.3%), dentistry (n=7, 6.5%), and pharmacy (n=6, 5.6%). Some papers included multiple health professionals regulated under the same body, such as physicians and osteopaths under the same board of medicine; these cases were counted as one profession.

Publications on Disciplinary Action Outcomes Over Time (N=108)
Figure 2.

Publications on Disciplinary Action Outcomes Over Time (N=108)

Studies examined any or all of the following: reasons for disciplinary action (84/108 studies, 78%), characteristics and predictors of those subject to discipline (90/108, 83%), penalties applied (68/108, 63%), and rates of disciplinary action (41/108, 38%). Most studies (n= 94, 87%) were observational studies which were largely retrospective cohort studies using administrative data such as regulatory body disciplinary action cases or federal databases of disciplinary action cases. An additional six (5.5%) publications were observational research combined with another type of research, such as qualitative, a review, a questionnaire, or analysis. Other study types included reviews (n=4, 3.7%), qualitative research (n=3, 2.8%), and surveys (n=3, 2.8%), which were typically older studies likely conducted before disciplinary action cases were available online.

Common reasons for disciplinary action

Reasons for disciplinary action were considered in 84 of the 108 studies (78%). Most studies reviewed all possible reasons for discipline in a profession or in multiple professions, while some studies investigated one or a few specific types of violations, such as improper prescribing of narcotics, diversion, or impairment,31,32,53,63,64,77,78,113 online professionalism,49,84 or sexual misconduct or boundary violations.13,14,37–39,58,63,76,95,103

Papers categorized reasons for discipline differently and often in broad categories, with little to no standardization in the definition of these categories. This limited the ability to determine the most to least common reasons. However, commonly cited reasons for discipline included clinical incompetence or standard of care issues, fraudulent financial practices, sexual misconduct, criminal conviction, alcohol or drug use/health impairment and unethical prescribing. Of the 84 studies looking at reasons for discipline, 52 (62%) focused on medicine and osteopathy, 11 (13%) on nursing, 6 (7.1%) on various health professions, 7 (8.3%) on dentistry, 4 (4.8%) pharmacy, and 1 (1.2%) each for psychology, social work, chiropractic medicine, and optometry/opticianry.

Penalties

Of 108 studies, 68 (63%) studied the types of penalties administered by the disciplinary body. Most papers that studied penalties analyzed one or more reasons for discipline and/or characteristics and predictors of disciplinary action. Some studies looked at factors related to the type of penalty administered, such as whether certain characteristics or predictors were associated with a higher risk of receiving a certain type of penalty,16,17,28,41,44,54,56, 62,67,73–75,79,80,89,93,94,98,101–103 whether the type of violation affected the penalty,28,34,39,70,71,80,100,119 or whether the presence of certain aggravating or mitigating factors affected the penalty.42,43,45,46,103 Two studies assessed effectiveness of penalties on rates of reoffending.27,65 Most papers studied penalties as a whole, commenting on the most and least commonly applied penalties in the sample,13–19,24, 28,29,31,32,34,36,37,40,41,47–50,57,61–63,65,69,70,72,74,76–78,80,82,84,88,93,98,101–103,106,108,112,113,118,119 while some papers looked specifically at one type of penalty and the types of cases that led to such a penalty, such as license revocation,19,26,34 or remediation.118

The types of possible penalties were similar across studies, and included formal reprimands, fines, paying the costs of the investigation, publication of the case details or outcome, conditions or limitations applied to the health professional’s license to practice, temporary license suspension, and license revocation (i.e., permanent loss of a license to practice, also referred to as license cancellation or erasure).

Characteristics and predictors of disciplinary action

Of 108 studies, 90 (83%) described one or more characteristics or predictors of disciplinary action. Characteristics and predictors researched included gender, age, years in practice, practice specialty, country of entry-to-practice education, board certification and maintenance of certification, performance on the licensing exam, license type (e.g., advanced practice nurse/nurse practitioner, registered nurse, licensed practical nurse), whether or not they had previous or repeated disciplinary action, and other (e.g., source of complaint, race/ethnicity). Overall, gender, practice specialty, years in practice, and license type were the most commonly studied. Characteristics and predictors are described below.

Gender

Fifty-nine of 108 publications (55%) considered gender as a risk factor for disciplinary action. Across professions, 41 publications found that male gender increased risk of disciplinary action. 14,15,17–19,24,25,27–29,33,36,38,48,54,56,61,62,66,69,74,75,79,80,88, 91,93,94,98,102,106–112,116,118–120 Twelve studies reported that most cases in the study were against males, but did not compare the proportion of males disciplined to the proportion of males in the general workforce for that profession.16,34,39,41,57,76–78,89,95,113 Five studies found no difference between male and female gender as a risk factor for discipline.22,26,87,101,103 Some studies from nursing found that more women were disciplined overall,58 but that more men were disciplined when compared to the proportion of males in the workforce.48,54,88 One study in the United Kingdom found that more cases relating to social media involved female dentists than male dentists,84 and another study found that while women were less likely to be disciplined overall, women were more likely to be disciplined severely.80

Age

Twenty-nine of 108 studies (27%) considered age as a predictor of discipline. For physicians, disciplinary risk increased with age, with highest risk between ages 40–59.13,19,33,37,38,67,69,77,78,89,91,102,106 Two studies on multiple professionals found risk increased with age, with those aged 56–65 having the highest risk,94,98 and one study on pharmacists found no difference with age.90 Regarding age at initial registration, one study found a higher risk of discipline for those who were 30 or older when they finished their training,75 but another study found lower risk of discipline for clinical concerns for those who were older at registration.107 Higher risk of a complaint with older age at registration but lower risk for a disciplinary critique was identified in one study.20 Another study found older doctors to be more likely to have a lack of insight into the problem and less likely to change their practice.65

In nursing, five studies found that disciplined nurses have an average age ranging from 43–51.5 years,48,54,58,61,118 and one review article identified a range of 20–76 years.88 Associations with younger age were found in some nursing studies, where one study found the average age of discipline to be 37 years, which was lower than the average age (43 years) of the nursing population in that study.27 Another study found nurses who recidivated to be three years younger than those who did not and were more likely to recidivate if less than 40 years.118 Certain violations were found to be more common in those of a younger age, such as more cases of chemical dependence in those aged 25–37,111 and more cases of sexual misconduct in those aged 25–54.14

Years in practice

Twenty-nine of 108 papers (27%) considered years in practice as a predictor of discipline. Research on years in practice is conflicting. For physicians, 10 studies 22,24,25,26,56,62,80,109,112,116 and one review article91 reported increased risk of disciplinary action with more years in practice or reported a higher proportion of physicians disciplined if they had more years in practice. In contrast, one study found disciplined physicians significantly more likely to be practicing fewer than 20 years at time of discipline.28 Ten studies reported an average number of years in practice before a disciplinary case for various specialties or for physicians in general, ranging from to 11 years to 33 years.15–17,20,29,34,36,74,85,113

Nurses appear to be disciplined sooner after graduation than physicians. One study reported an average of 12 years in practice before first discipline,61 another study reported that 60% of nurses were disciplined within the first 10 years of practice,111 and a review article also found an average of 12–14 years before first discipline.88 One study reported that nurses usually had more than six years’ experience but had also recently changed employment or practice area within a year of the incident leading to disciplinary action.48

Practice specialty

Forty-two of 108 papers (39%) included practice specialty as a risk for disciplinary action. Across 22 studies on physicians, the specialties of family medicine, psychiatry, obstetrics/gynecology, general practice, surgery, and anesthesiology were found to have a higher risk of discipline.15,17,25,26,28,34,36–38,50,56,57,63,76–78, 80,86,87,91,95,113 Lower risk was found with radiology,69 pediatrics,69 internal medicine,62 and cardiology,62 and one study found no association with specialty.19

Two studies found that anesthesiologists were less likely to be disciplined than other specialties,16,24 but one study found anesthesiologists at high risk for addiction,64 and another found them more likely to be disciplined for alcohol and drug offenses.25

Risk has also been studied for subspecialties. Of physical medicine and rehabilitation physicians, the highest disciplinary risk was seen in those who had a subspecialty in pain.66 Among internal medicine physicians, highest risk was seen among general internal medicine, then cardiology, and less risk with rheumatology, endocrinology, respirology, gastroenterology, hematology, and medical oncology.74

Among nurses, those in medical-surgical nursing were disciplined the most, with other higher risk specialties including geriatrics and long-term care, anesthesia, critical care, and emergency.48,111 Another study found long-term care nurses to be disciplined disproportionately more compared to the number of long-term care nurses in the general population.118

Board certification

Seventeen of 108 papers (16%) focused on board certification. All 17 papers considered physicians and found that certification decreased risk of disciplinary action compared to non-board-certified physicians. Specialties studied included anesthesiology,120 emergency medicine,83 family medicine,89 general surgery,59 internal medicine,73,75,85 orthopedics,68 physical medicine and rehabilitation,66,67 psychiatry91 and physicians in general.28,33,62,69,80 Studies also found that those who passed the certification exam on the first attempt had lower risk of discipline than those who required multiple attempts.59,66,75,83,85 Risk was also lower for those whose certification never lapsed, while those who let their certification expire before recertifying had a higher risk of discipline.67,75,83,89 Those who had been in practice for a longer duration since completing their mandatory specialist training also had a higher risk of discipline.20 Scores on certification exams were associated with discipline risk, with lower scores having a higher risk of future disciplinary action.66,67,75,85 Board-certified physicians also were less likely to receive a severe penalty and more likely to receive a less severe penalty.33,67,73,75,89 One study found that higher scores on the board certification exam reduced the likelihood of disciplinary action for both domestic and international graduates, but that it was more protective against disciplinary action for domestic graduates than for international graduates.85

Performance on licensing exam

Performance on licensing examinations was considered in six of 108 publications (5.6%). Four studies29,87,93,112 and a review article33 found that higher licensing examination scores or mandatory post-graduate examination scores were associated with a lower risk of future discipline for physicians and osteopaths. In nursing, one publication studying characteristics of nurses disciplined for chemical dependency found that 2/35 nurses failed the licensing exam on the first attempt, but no further conclusion was made by the authors.111

International entry-to-practice education

Twenty-six of 108 papers (24%) considered international entry-to-practice education. Research on whether being an international graduate increases risk of future disciplinary action is conflicting. Nine studies 15,16,24,35,62,66,69,109,112 and two review articles33,91 found that international graduates were at higher risk of disciplinary action than domestic graduates, and one found an increased odds ratio for discipline with overseas training but it was not statistically significant.90 Another study found that international graduates were more likely to receive high impact decisions in every stage of the disciplinary process and were more likely to be suspended or have their license revoked.56

However, six studies25,26,28,83,89,119 found that international graduates were not at higher risk of disciplinary action, and one study found that notifications against internationally-trained psychologists were more likely to result in further investigation but not more likely to have disciplinary outcomes or conditions applied.102 One study found no association between place of education and risk of a complaint.20 A few studies collected information on international medical graduates but did not compare discipline rates or risk to domestic graduates.17,57,74,107

License type/profession

License type within a profession (e.g., registered practical nurse, registered nurse, or nurse practitioner) was studied in 31 of 108 papers (29%). License type was associated with discipline, where those with less education were more likely to be disciplined. Among nurses, six papers found that licensed practical nurses or licensed vocational nurses were at highest risk of discipline compared to the general nurse population, followed by associate degree or diploma nurses, and then nurses who had earned a bachelor’s degree.14,27,48,58,61,118 Advanced practice registered nurses were the least likely to be disciplined, but among this group, nurse practitioners were at highest risk for discipline and certified registered nurse anesthetists were at lower risk.55 Studies that did not compare rates of discipline to the general nurse population found that most cases concerned registered nurses,54,88,111 which makes sense given the proportion of registered nurses in the nurse workforce. An exception to this was a study in dentists, which found that dentists had the highest rate of complaints compared to allied dental professionals and to other health professions.106

Compared to allopathic physicians, osteopaths had a higher risk of discipline,25 non-significant higher risk of revocation,26 and higher risk of discipline for sexual misconduct.37,95 Among pharmacists, one study found that pharmacy technicians were more likely to divert medications than pharmacists; the authors attributed this to the relative investment in the profession, with technicians having less educational and financial investment than pharmacists and therefore were more likely to divert overall.32

Three papers compared discipline rates between professions: One found that most cases involved doctors, nurses, and pharmacists;101 one found that chiropractors had a higher rate of complaints than osteopaths and physiotherapists;94 and one compared the rate of discipline based on the number of practitioners for each profession, finding that dentists had the highest rate, followed by doctors, while nurses and midwives had the lowest rate.98 One study looking at consensual sexual misconduct cases found that nurses had the most cases, followed by doctors, then psychologists, which mirrored the general health practitioner workforce.103 Another study on sexual misconduct found that osteopaths and podiatrists had higher risk than allopathic physicians.39

Previous disciplinary action

Across professions, 25 of 108 publications considered previous disciplinary action or multiple violations as a risk factor for future discipline. Seven studies found that most discipline cases involved multiple violations or repeated charges. 24,33,40,66,80,87,92 Previously disciplined physicians were more likely to be subject to future discipline than physicians who have never been disciplined,47 and one study found higher risk of license revocation with two or more previous actions compared to one previous action.26 Seven papers reported on the rate of discipline for physicians in general or certain specialties who had been previously disciplined, ranging from 8% of physicians to 45.5%.15–17,28,57,89,113 In two pharmacist studies, 18% and 20% of pharmacists were disciplined more than once,90,108 and five studies of nurses reported rates ranging from 6.6% to 39% with an average of 23%.27,54,58,61,118 In a study reviewing multiple health professionals, 8.7% of guilty findings involved previously disciplined practitioners.101

Factors associated with recidivism for nurses included previous criminal conviction, multiple violations, younger age, male gender, and being a licensed practical nurse.118 One study found that the most common reason for recidivism among nurses was alcohol and drug problems, and that there was a higher recidivism rate if there were less conditions placed on the license or if suspension was not given as a penalty.27 For physicians, risk factors for repeated discipline include noncompliance with conditions on license,19 younger age,53,63 longer time since offense,63 lack of insight63 and being disciplined for drug abuse.53 One study found that most repeat offenders were male, independent practitioners, and practiced in the specialties of family medicine, psychiatry, surgery, and obstetrics/gynecology.57 Decreased risk was found with a one-off, isolated incident and feeling of remorse by the clinician.63

Rate of disciplinary action

Forty-one of 108 studies (38%) reported on rate of complaints or disciplinary action. Discipline rates overall across professions were low. Metrics used to report rates differed and included a percentage of practitioners,15,16,28,29,44,61,62,67,75,80,83,85,86,89,92,93, 102,108,117,120 number of cases per 1,000 or 10,000 practitioners,19,30,36,40,41,52,98 number of cases per 1,000 practitioner-years,35,74,119 or cases per practitioner per year.17 Studies found that less than 1% of osteopaths were disciplined,93 less than 2% of psychologists,102 0.001% to 1.8% of pharmacists,44,108 and 0.19% of nurses.61 Some studies found variation across jurisdictions within the same country, such as U.S. dentists (ranging from 0.35 cases per 1,000 dentists to 19.20 cases per 1,000 dentists),30 and U.S. physicians (ranging from 1.74 to 10.27 cases per 1,000 physicians).52

For physicians, 28 studies reported discipline rates. Discipline rates overall were low. Of those reporting discipline as a percentage of physicians over time, rates ranged from 0.06% to 7% of physicians per year, with an average of 2.24%.15–17,20,28,29,62,67,75,80,83, 85,86,89,117,120 One study reviewing multiple health professionals from Australia found an overall rate of 6.3 notifications per 1,000 practitioners per year, but varied between professions with dentists having the highest rate of notifications (20.7 notifications per 1,000 practitioners per year), followed by doctors at 14.5, pharmacists at 6.8, and nurses and midwives with the lowest rate at 2.0.98

Studies across professions reported an increase in discipline cases over time,27,36,61,79,99,101 but one study in dentistry reported no difference in percentage of sexual misconduct complaints over the five-year study period.39 Possible reasons for increases in discipline rate include an increase in the health practitioner workforce over time,101 change in disciplinary action structure,101 targeting of certain violations,19,79 change in board composition,19 and changes in laws resulting in more cases being heard by disciplinary boards.99

Discussion

This scoping review describes the research that has been done to characterize the outcomes of disciplinary action or fitness-to-practice cases for regulated health professionals. Many studies have focused on reasons for discipline and various characteristics and predictors associated with discipline. Overall, included publications highlighted that the following characteristics were associated with discipline: male gender, older age, more years in practice, certain physician specialties, license type, previous disciplinary action, lack of board-certification, and poor performance on licensing examinations. However, research for these characteristics was not always in agreement. Most research has focused on physicians and originates from the United States. As most research has been done in the last 10 years, this review has highlighted the increased interest in this research area. However, variation in discipline processes and a lack of standardized definitions continue to make comparisons difficult.

This review adds to the literature on regulatory body disciplinary action because it includes multiple professions and jurisdictions, and broadly looks at reasons for discipline as well as characteristics and predictors of discipline. While Papinaho et al.’s integrative review identified studies from four countries, it focused on nurse disciplinary action only.88 Unwin et al.’s systematic review focused on how medico-legal action differs with gender,110 and Reich and Maldonado reviewed malpractice and regulatory body discipline for psychiatrists only.91 Other publications have reviewed disciplinary action for multiple health professions but focus on one jurisdiction.98,114 In contrast, our review takes the broadest lens looking at multiple factors and professions across multiple jurisdictions.

Creation of a profile of characteristics such as gender, age, or ethnicity to identify those who are at risk of being subject to discipline is tempting, but discipline is rare. Most practitioners that fit these characteristics do not go on to offend, and such a checklist could drive discrimination and may in fact be more reflective of systemic bias.33 Aside from characteristics and predictors related to health professionals themselves, discipline is also influenced by each jurisdiction’s disciplinary action process, health care system, educational model, licensing requirements, quality assurance requirements, and culture. Interplay between these predictors and societal factors needs to be understood in order to address these risk factors and to interpret the usefulness of research on predictors of disciplinary action.

For example, many researchers have concluded that men are more likely to be disciplined than women, although the reasons behind this are not clear. In their systematic review and meta-analysis, Unwin et al. determined that this difference was not due to more males in the physician workforce. Possible reasons for the difference include differences in how genders are treated by the public or the regulator, or differences in work patterns, as female doctors are more likely to work part-time and see less patients than men, which could decrease overall patient encounters and the risk of disciplinary action.109,110 Some researchers attribute the difference in risk across genders to communication differences,74,109 where females spend more time with each patient and are more engaged with patients in conversation, decision-making, and partnership-building.109 Future research could investigate the possible reasons behind the difference in risk for discipline across genders, such as greater emphasis on communication in undergraduate training.

One particular area of controversy is whether international education increases the risk of disciplinary action. Of the 25 studies that identified this, all were conducted in Western countries and typically compared domestic graduates to international graduates as a group. In a few studies, a small number of countries were grouped together and compared to international graduates, such as the European Union or Canada and the United States. One study profiled risk according to country of qualifying education, highlighting that countries with higher risk than domestic Australian graduates were from non-Western countries.35 Another study found that both doctors qualifying within the European Union and outside the European Union were more likely to receive a high-impact disciplinary decision than domestic United Kingdom graduates.56 These studies are an opportunity to highlight systemic racism and the barriers that minorities and immigrants experience. Differences in discipline rates could be due to cultural differences, English not as a first language, differences in health systems, and communication skills — for example, the ability to explain clinical decision making, deescalate a situation, or apologize to a patient.35,56

It is possible that a systemic bias is at the root of the increased rates of international graduates in certain countries on the patient/client side who report to the regulator, or on the side of the disciplinary committee who may use international training as a predictor to prompt closer scrutiny of a practitioner. A 2019 study on organizational discipline processes in the National Health Service organizational found that Black, Asian, and minority ethnic staff were overrepresented in disciplinary action.122 This was attributed to a number of factors, including a closed organizational culture that was not easily challenged, lack of cultural competence in senior staff, unfair decision making, lack of support for those undergoing disciplinary action, lack of standardized application of disciplinary processes, and disciplining staff that had attitudes or behaviors that deviated from the norm even if there was not a performance issue.122 This study highlights that many factors aside from personal characteristics affect disciplinary action. With the significant focus on systemic racism throughout multiple institutions in society, this is perhaps an inflection point where data collected on international graduates or race may need to be revisited for use to support equity rather than to identify individuals for discipline.

The final consideration for this paper is that there is little research on the effectiveness of penalties for preventing reoffending. As a comparator, research in quality assurance and maintenance of competence programs has shown that programs involving peer-assessment and practice-based assessment are most effective in ensuring competence with less clear evidence for commonly used strategies such as continuing education credits/professional development requirements or learning portfolios.123 A similar lens should be applied to discipline, where the goal of evaluation is to determine if disciplinary measures are actually effective in preventing reoffending. Little evidence exists for the efficacy of disciplinary penalties. Kiel argues that the use of conditions on a practitioner’s license is not effective in protecting the public,65 and while one study in nursing found that more conditions placed on a license and the use of suspension was associated with lower reoffending rates, this study was from 1999 and used a sample from one U.S. state.27 Further comparison of disciplinary action penalties with quality assurance programs could be useful, recognizing that many factors such as funding and resources as well as regulatory body culture affect disciplinary action rates.21,52

A few limitations should be considered. First, each jurisdiction has a different system to handle complaints and disciplinary action. Some regulators distinguish between the complaints process and the higher-level disciplinary action process that handles serious cases or cases where the parties cannot come to an agreement. However, other jurisdictions might not make this same distinction and studies from such jurisdictions might report complaints only. Papers on complaints data were excluded if it was determined that those jurisdictions had a separate process for higher-level disciplinary action cases. Papers that reported on both complaints and discipline processes were included in order to extract data on disciplinary action only. A few papers that reported complaints data only were included if it was decided that the essence of the process was analogous to disciplinary action, and that the difference was due to that jurisdiction’s system of handling such cases. Inclusion of studies focusing on complaints might overestimate the risk of demographic factors or reasons for discipline as some complaints are dismissed, and some complaints are resolved through mediation and might not result in a penalty. This highlights the difficulty in collecting data across different jurisdictions. Second, some full-text publications were not available due to limited library operations as a result of the COVID-19 pandemic and were excluded.

Conclusion

In this scoping review, we identified that a significant body of research has characterized the reasons for discipline, penalties, and characteristics and predictors of health practitioners subject to disciplinary action. Areas for future research are numerous. As most of the available literature has been conducted in the United States and has focused on physicians, more research from other jurisdictions and other professions is needed. While various characteristics and predictors of disciplinary action have been studied, an area for future research is how this information can be used to develop strategies to decrease disciplinary action and support health practitioners. This review also identified that many studies have assessed the types of penalties administered, but more research is needed about the efficacy of penalties in reducing the rate of reoffending and ensuring competence. This research is important for state boards, other regulators, and independent disciplinary councils who conduct disciplinary investigations. This research is highly relevant to the United States, where interstate medical licensure compacts have grown significantly in recent years.124 Such compacts create a prime opportunity for comparison and for standardization of state board practices in a few areas, including the reporting of disciplinary action cases, the register of professionals, types of violations that are disciplined, and types of penalties that are applied.

Acknowledgements

Ai-Leng Foong-Reichert was funded by the Ontario Graduate Scholarship and the Canadian Institutes of Health Research.

Appendix A: Search Strategy

PubMed Search Strategy (Literature Search performed June 5, 2020):

(pharmacists[mesh] OR pharmacist* OR physicians[mesh] OR physician* OR doctor* OR nurses[mesh] OR nurs* OR “nurse practitioners” [mesh] OR “nurse practition*” OR dentists[mesh] OR dentist* OR “allied health personnel”[mesh] OR “allied health personnel” OR “pharmacy technician*” OR anesthetists[mesh] OR anesthetist* OR anaesthetist* OR chiropract* OR “massage therap*” OR midwif* OR midwive* OR naturopath* OR osteopath* OR audiologists[mesh] OR audiologist* OR dental staff[mesh] OR “dental staff” OR nutritionists[mesh] OR nutritionist* OR dietician* OR dietitian* OR “speech language path*” OR chiropod* OR podiatr* OR homeopath* OR kinesiolog* OR “laboratory technician*” OR “radiation technolog*” OR optician* OR psycholog* OR psychotherap* OR “respiratory therap*” OR acupunctur* OR sonograph* OR “emergency medical technicians”[mesh] OR “emergency medical technician*” OR paramedic* OR “occupational therapists”[mesh] OR “occupational therapist*” OR optometrists[mesh] OR optometrist* OR “physical therapists”[mesh] OR “physical therapist*” OR physiotherap* OR “health personnel”[mesh] OR “health personnel” OR “healthcare provider*” OR “health care provider*” OR “health care personnel” OR “healthcare personnel” OR “health care professional*” OR “healthcare professional*” OR “regulated health profession*”) AND (“disciplinary action*” OR “disciplinary procedure*” OR “disciplinary proceeding*” OR “employee discipline”[mesh] OR “employee discipline” OR “fitness to practice” OR “fitness to practise”)

Appendix B: Data Extraction Form Sample

View this table:

Appendix C: Characteristics and Results of Included Studies

To view Appendix C online, please visit http://hdl.handle.net/10012/17896

About the Authors

  • ↵Ai-Leng Foong-Reichert, BSc, PharmD, is a PhD Candidate at the University of Waterloo School of Pharmacy.

  • ↵Ariane Fung, BSc, PharmD, was a student at the University of Waterloo School of Pharmacy at the time the paper was written and will soon begin a hospital pharmacy residency.

  • ↵Caitlin A. Carter, BA, MLIS, is the Liaison Librarian at the University of Waterloo School of Pharmacy.

  • ↵Kelly A. Grindrod, BScPharm, PharmD, MSc, is an Associate Professor at the University of Waterloo School of Pharmacy.

  • ↵Sherilyn K.D. Houle, BSP, PhD, is an Assistant Professor at the University of Waterloo School of Pharmacy.

  • ↵* Note to readers: Due to the length of Appendix C, which totals more than 45 pages, it is not included in the print version of this edition of JMR. A link to an online-accessible version of the appendix is included at the end of this article.

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In this Issue

Journal of Medical Regulation

Vol. 107, Issue 4

1 Dec 2021

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