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The Impact of Incivility on Hospital Patients


How relational tension in the OR can affect patient outcomes.

Boss yelling at employee

Negative interactions in the hospital operating room (OR) can pose a direct risk to the patient, according to a new study.

The multicenter, prospective, randomized control trial study, published in the British Medical Journal’s Quality and Safety, found that incivility and rudeness in the operating room can pose a distinct threat to patient safety, affecting residents’ technical and non-technical performance across domains such as vigilance, diagnosis, communication, and patient management. 

The study was conducted across the anesthesiology departments of three academic medical centers: the Icahn School of Medicine at Mount Sinai in NYC, the University of North Carolina at Chapel Hill, and Ohio State University. Although the study focused on anesthesiology residents, its authors believe that that the typical OR triad of surgeon-anesthesiologist-circulating nurse could be affected in various directions if exposed to impatient, dismissive behavior. 

As a result of this trial, researchers believe it imperative that rude, uncivil behavior be eliminated from operating room culture and that interpersonal communication in such high-stress environments be incorporated into formal medical training.

“In most circumstances, when we are confronted with rude, dismissive, or abusive behaviors, we are more or less hardwired to avoid their perpetrator,” says study author Samuel DeMaria, Jr, MD, professor of anesthesiology, perioperative and pain medicine at Mount Sinai. “However, in the OR, where interdisciplinary communication is crucial to patient outcomes, things are a little more high stakes. We found that a negative interaction should not simply be dismissed as an unpleasant occurrence, because it can actually pose a direct risk to the patient.”

Related article: Motivational Interviewing Improves Patient Outcomes

DeMaria and colleagues also learned that even “run-of-the mill” incivility on the part of the surgeon (e.g., impatience, referring to someone by their job function rather than their name) can significantly hinder resident performance across the behavioral/communication and medical/technical domains.

“Additionally, we found that the study participants weren’t aware of the degree to which their performance was impacted by the incivility they experienced,” he says.

Providers perform

Mount Sinai Hospital has a large anesthesiology residency program at the Mount Sinai Hospital (approximately 100 residents). “As an academic center, our trainees are involved in most of the anesthetics we provide every day,” DeMaria says. “As such, we are always looking for ways to do better and support our trainees, whether through their own training or through systems improvement. Part of the obligation to constant improvement means staying out ahead of issues that may be impacting the care we provide, which includes finding out how our providers perform amid rare and critical situations and behaviors-some of which they may only encounter a handful of times in their careers.”

By and large, according to DeMaria, the working relationships in Sinai’s ORs are “fantastic and highly patient-centered. But we’re also cognizant that, like any sizable academic center, there is always room for improvement-and many residents may, of course, choose to accept positions elsewhere upon graduation. We’re committed to making this an enriching environment in which our residents can thrive, so it’s crucial that we identify any issues that might be holding them back.” 

With this study, DeMaria and colleagues wanted to understand how an encounter with a “prickly” surgeon impacts residents, if at all, in a crisis. The researchers used a simulated unrecognized hemorrhage scenario, as it requires several key aspects of quality anesthetic care: crisp communication of the problem with the rest of the OR team, and the ability to rapidly diagnose and treat the problem when seconds count.

“We hoped that a few snide remarks from our simulated surgeon and a few staged conflicts between the surgeon and the OR nurse would have no effect on residents’ medical/technical and behavioral/communication performances,” he says. “What we found was quite the opposite, and we hope this serves as a wake-up call for providers: our behaviors and relationships with one another do count, and can hurt patients.” 

It is hard to accurately measure culture at any given hospital, but healthcare execs should acknowledge that a burnt-out workforce trained in the traditional healthcare ‘school of hard knocks’ will guarantee uncivil behaviors are occurring, at least occasionally, according to DeMaria.

“Getting out ahead of these behaviors through provider wellness initiatives, and inter-disciplinary training programs that foster a culture of safety and patient-centeredness, is money well spent,” he says. “This may be hard to swallow for many execs, since the return on investment isn’t always immediately reflected on the balance sheet. However, such initiatives could potentially improve patient care and mitigate risk, while contributing to a positive work environment that furthers recruitment and retention initiatives. It’s no secret that demand for talented medical staff is rising, and that recruitment costs can make a significant dent in an organization’s bottom line, so it’s critical that healthcare providers and executives alike make a concerted effort to establish-and maintain-a strong culture of civility and collaboration.” 

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