Exposure to incivility hinders clinical performance in a simulated operative crisis

Abstract

BackgroundEffective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.MethodsThis is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or ‘rude’ environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups.Results76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112).ConclusionAlthough self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

Psychological safety in feedback: What does it look like and how can educators work with learners to foster it?

“…This is important for learning outcomes as excessive anxiety distracts attention, interferes with complex thinking and impairs memory 7‐34,59 . This theme aligns closely with guidelines for simulation‐based education and doctor‐patient communication skills, which outline the importance of setting the tone for a collaborative partnership from the start 35‐58 …”

“…The effect of psychological safety on learning and performance has been demonstrated in other areas of health care 35‐38 . In simulation‐based education, the importance of psychological safety is particularly emphasised; it is explicitly labelled as a goal at the outset and both educators and learners commit to ground rules that ‘realise it’ in practice 39‐41 .…”

Social emotion and patient safety: an important and understudied intersection

“…Emotion in clinical settings is not only influenced by the patient; the healthcare professional will arrive at work in a certain mood and the department will have an emotional climate or tone, influenced by relationships and interactions in the team. Several studies have shown that exposure to rudeness and incivility affect clinical performance, [15][16][17] and in the studies by Isbell and colleagues, healthcare providers discussed being influenced by emotion at a social as well as individual level. Factors such as consultants being perceived as uncooperative or unhelpful, the respect and appreciation felt towards colleagues as part of their 'community', and system-level factors such as 'overcrowding' were identified by clinicians as emotional triggers.…”

Psychological safety and gratitude may bring us closer to our core value

“…Interestingly, not showing gratitude and displaying outright rudeness may be counter‐productive to the operating teamʼs performance. There is a recent study showing rude surgeons could impair anaesthetists performance . The percentage of resident anaesthetists performing at an expected level dropped from 91.2% to 63.6% when they were working with a rude surgeon.…”

“…There is a recent study showing rude surgeons could impair anaesthetists performance. 6 The percentage of resident anaesthetists performing at an expected level dropped from 91.2% to 63.6% when they were working with a rude surgeon. Although some may argue that the study was conducted in a standardised simulation scenario of occult haemorrhage, it should not be difficult to envisage from our personal experience of working with surgeons who are rude, abusive and impolite.…”