Why is this important?

Medical crises are high stress, and do not always bring out optimal behaviour in clinical teams. Although progress has been made to improve operating room cultures, the specific consequences of ‘incivil’ behaviour in anaesthesiology have not been previously defined.

Katz and team set out to identify the effect of incivility on performance during a simulated operating room crisis (intraoperative haemorrhage), noting that multiple surveys show the ubiquity of incivility in surgical and anaesthetic environments.

“Incivility is a potential source of interpersonal conflict and a latent threat to effective communication...” – Katz et al.

What did they do?

Across three institutions, 76 anaesthesiology residents were randomised to crisis simulation encounters with or without incivility (“rude, dismissive or aggressive behaviour”), expressed by the simulated surgeon through scripted dialogue and demeanour.

“The experimental group’s surgeon was portrayed as impatient, but not overtly intimidating (ie, actors were instructed not to use inappropriate language, become physically intimidating or scream). The control group’s surgeon was courteous and the interactions straightforward.”

Participant performance was independently assessed in three ways:

1. Completion of checklist items expected for the crisis.
2. Ratings for vigilance, decision-making, teamwork and communication.
3. Whether performance was consistent with level expected of anaesthesiology resident.

Exposure to incivility lowered performance across every metric

Also notable, exposed participants believed that the environment negatively effected performance, even though self-reported performance assessment was comparable between groups.

91% of the control group were rated as performing at their expected level, but only 64% of the incivility-exposed group. Quality of decision making was particularly vulnerable to incivility, as were vigilance, communication and teamwork.

Take-home message

Professional conduct and civil behaviour is another important non-technical skill, consequential to crisis performance. We should already appreciate that incivility has no place in the high-stakes environment of an operating theatre, if for no other reason than it’s not civil.

Anaesthesiologists should also be aware of how their behaviour may effect the performance of their colleagues.

summary

• Daniel Katz, Kimberly Blasius, Robert Isaak, Jonathan Lipps, Michael Kushelev, Andrew Goldberg, Jarrett Fastman, Benjamin Marsh, and Samuel DeMaria.
• Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA daniel.katz@mountsinai.org.
• BMJ Qual Saf. 2019 Sep 1; 28 (9): 750-757.

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.© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.

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