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Incivility in Operating Rooms Associated with Diminished Clinical Performance

Analysis  |  By Christopher Cheney  
   June 10, 2019

Even 'run of the mill' instances of rudeness in operating rooms can lower the performance level of surgical team members.

Research on anesthesiology residents exposed to incivility in a simulated operating room environment indicates that rudeness in the OR has a negative impact on clinician performance.

In healthcare settings, effective communication is considered essential for patient safety and clinical quality. The stakes are particularly high in the perioperative environment, where poor communication can lead to negative events.

The recent research published in BMJ Quality & Safety exposed anesthesiology residents to an impatient surgeon-actor in a simulated OR hemorrhage scenario. Compared to a control group of residents who were not exposed to an impatient surgeon-actor, the experimental residents scored lower on all four performance metrics in the study: vigilance, diagnosis, communication, and patient management.

A co-author of the study told HealthLeaders that the research shows there is a high degree of sensitivity to incivility in the OR setting.

"What we learned is that even 'run of the mill' incivility on the part of the surgeon such as impatience or referring to someone by their job function rather than their name can dramatically hinder anesthesiology resident performance in the behavioral-communication and medical-technical domains," said Samuel DeMaria Jr., MD, a professor in the Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai in New York.

DeMaria said it is probable that incivility in the OR setting can have a negative performance impact on other members of the surgical team. "It is very likely that the typical OR triad of surgeon-anesthesiologist-circulating nurse could be affected in various directions if we chose to expose one or several of those people to an uncivil party," he said.

Incivility by the numbers

The research was conducted at three academic medical institutions: Mount Sinai Health System in New York, Ohio State University in Columbus, and the University of North Carolina in Chapel Hill. The simulated OR scenarios were videotaped, and 67 simulations were examined.

The study generated several key data points:

  • In a measurement of overall performance, 91.2% of the control group received a passing score. Only 63.6% of the residents exposed to the impatient surgeon-actor obtained a passing score.
  • In the experimental group, more than 65% of residents reported that the OR environment had a negative impact on team performance.
  • In the control group, less than 25% of the residents reported that the OR environment had a negative impact on team performance.
  • There was no significant difference in self-reported ratings of individual performance between the two groups.

"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 behaviors be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training," the researchers wrote.

Consequences and mitigation

Incivility in the OR setting can have serious negative consequences, DeMaria told HealthLeaders.

"Social interactions are highly complex, especially in stressful environments like the OR. When we are confronted with rude, dismissive or abusive behaviors, we are more or less hardwired to avoid their perpetrator. In the OR, where inter-disciplinary communication is crucial to patient outcomes, a negative social interplay is not simply a relational stressor but also a direct risk to the patient," he said.

Incivility in the OR needs to be addressed at the institutional and the individual level, DeMaria said. "We would all benefit from more widespread interdisciplinary training and mutual respect, but in an industry where burnout is rising and the culture is often perceived as toxic, we need to accept that effecting meaningful change starts with our own individual behaviors."

There are effective strategies that anesthesiology residents can utilize to address an uncivil surgeon such as escalating the situation to their attending supervisor, he said. "A just culture means these behaviors should not be tolerated; however, the best environment to discuss these issues is often not in the operating room, and especially not during a crisis."

DeMaria said residents should also be aware that poor interactions can have a negative impact on performance in the ORโ€”and act accordingly.

"If you suddenly find yourself loathe to communicate with the surgeon, even if you know you should, this is natural but potentially dangerous. If an important piece of clinical information should be communicated, you need to find that assertive part of you, and use it!"

Christopher Cheney is the CMO editor at HealthLeaders.


Effective communication is essential in healthcare settings, particularly in the operating room.

Poor interactions in the OR are highly probable to have a negative impact on all members of the surgical team.

Incivility in the OR needs to be addressed at the institutional and the individual level.

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