Exposure to incivility hinders clinical performance in a simulated operative crisis

Correspondence to Dr Daniel Katz, Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai Department of Anesthesiology Perioperative and Pain Medicine, New York city, NY 10029, USA; [email protected]

Introduction

Effective communication is a cornerstone of safe patient care, along with clinical excellence.¹ This is particularly true in the perioperative environment, where a lapse in communication between team members can permit rapid precipitation of adverse events.^{2 3} One potential threat to communication and medical/technical skills in the operating room (OR) is incivility, defined here as rude, dismissive or aggressive (RDA) behaviour(s) that impede professional relatedness.

Incivility creates interpersonal conflict and can impair diagnostic and technical performance,^{4 5} thereby increasing patient safety risks.^{2 6} The negative consequences of incivility have been well described in non-medical industries as well,⁷ where researchers have shown that even witnessing workplace incivility impairs performance and attention.^{8 9} Incivility is a pervasive issue for anaesthesiologists; 98% of anaesthesiologists in one survey reported being exposed to disruptive behaviours,¹⁰ and trainees have reported being subjected to RDA behaviours several times per week.⁶ The hierarchical structure of surgical teams may engender an atmosphere of intimidation and impede residents’ likelihood to challenge superiors (in their own specialty or otherwise), even when something unsafe or medically deleterious is occurring.^{11 12}

The vast majority of attending anaesthesiologists believe that residents are comfortable voicing concern and communicating with surgeons on their own. However, only half of residents surveyed report that this is the case.^{13 14} Efforts to provide residents with tools for challenging OR hierarchy and dealing with difficult communications have varied in their effectiveness, but the presence of these efforts is a clear display of need.^15–17 Indeed, struggles among team members in the OR have been a known issue in anaesthesiology for decades. Gaba et al ¹⁸ reported survey data 25 years ago that showed anaesthesia providers experience internal pressures to ‘get along with surgeons’ and external pressures to proceed with cases or hasten their work, leading to lapses in patient care. In the interim, little has been done to examine exactly how these pressures, and the incivility that often drives them, affect medical/technical and non-technical performance required for the safe provision of anaesthesia.

In...