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What’s New in the Patient Safety World

August 2019

More on the Cost of Rudeness

 

 

Our July 2012 What’s New in the Patient Safety World column “A Culture of Disrespect” summarized what Lucian Leape considers to be the number one problem in patient safety today: we have a culture of disrespect. Leape noted that the problem is not just that of the obvious disruptive physician who yells at people, throws things, etc. Rather, there are much more subtle behaviors that are equally disrespectful, and all are threats to teamwork and patient safety.

 

Then, in our September 22, 2015 Patient Safety Tip of the Week “The Cost of Being Rude”, we highlighted a study by Riskin et al. (Riskin 2015).that demonstrated the negative impact of rudeness on diagnostic and procedural performance in a very clever randomized controlled trial in a simulated environment.

 

Once again, Riskin et al. (Riskin 2019) conducted a study of primarily nurses in a general hospital which explored the impact of rudeness on patient safety performance, “state depletion” (that is, exhaustion of mental energy for reflective behavior), and team processes (for example, information sharing). A total of 231 rudeness incidents were reported in 98 shifts (out of 480 shifts analyzed). Most rudeness incidents stemmed from a patient or family. After a rudeness exposure, compliance with hand hygiene was significantly lower (for up to 24 hours following the exposure). Rudeness also led to decreased information sharing and increased team member’s state depletion. The adverse indirect effect of shifts’ temporal proximity to rudeness on poor compliance with medication preparation and team members’ information sharing via state depletion was significant. Rudeness exposure was also associated with increased rate of adverse events in the subsequent 24 hours, although this association was not statistically significant.

 

Another recent study in a simulated operating room scenario demonstrated that incivility had a negative impact on performance (Katz 2019). Katz et al. randomly assigned anesthesiology residents to either a normal or ‘rude’ environment and subjected them to a validated simulated operating room crisis. The “rude” environment included an impatient surgeon-actor in a simulated OR hemorrhage scenario. They measured both technical and non-technical performance domains including vigilance, diagnosis, communication and patient management. 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). It was particularly stroking that multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects (self-reported performance assessment was similar between groups).

 

They note that incivility doesn’t have to mean ranting and raving behavior. It can involve much more subtle behaviors, such as failure to use someone’s name (instead, calling them out by their function). You’ll recall from our July 2012 What’s New in the Patient Safety World column “A Culture of Disrespect” that Lucian Leape had also stressed the more subtle ways that disrespect is conveyed. Indeed, a new study (Torres 2019) shows that “microaggressions” in medicine and surgery can create stresses that are worse than those caused by overt behaviors. Microaggressions are subtle forms of prejudice and discrimination. The authors categorize them as microassaults, microinsults, microinvalidations, and environmental microaggressions. Examples include slights, humiliation, snubs, dismissals, general disrespect, devaluation, and exclusion. Microaggressions are often directed at minorities and women. The authors go on to describe ways to recognize microaggressions and how to respond to them.

 

And yet recent another study (Cooper 2019) found that patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. The researchers were able to use data from medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports. Despite the higher complication rate for surgeons with more reports, there was no difference between groups for mortality, need for second operations, or readmission within 30 days.

 

In the accompanying editorial Emerel et al. (Emerel 2019) use the analogy to the #MeToo movement to make the point we can no longer tolerate workplace hostility. Hospitals can no longer “look the other way” and let unprofessional behavior go unaddressed. Medicine and surgery, in particular, is a “team sport” and any negative interactions within the team can lead not only to poor team function, turnover, and burnout, but also to poor patient outcomes.

 

 

Some of our prior columns on the impact of “bad behavior” of healthcare workers:

 

January 2011               “No Improvement in Patient Safety: Why Not?

March 29, 2011           “The Silent Treatment: A Dose of Reality

July 2012                    “A Culture of Disrespect

July 2013                    “"Bad Apples" Back In?

July 7, 2015                “Medical Staff Risk Issues

September 22, 2015    “The Cost of Being Rude

April 2017                   “Relation of Complaints about Physicians to Outcomes

October 2, 2018          “Speaking Up About Disruptive Behavior

 

 

Some of our prior columns related to the “culture of safety”:

 

April 2009                   “New Patient Safety Culture Assessments

June 2, 2009                “Why Hospitals Should Fly...John Nance Nails It!

January 2011               “No Improvement in Patient Safety: Why Not?

March 2011                 “Michigan ICU Collaborative Wins Big”).

March 29, 2011           “The Silent Treatment: A Dose of Reality

May 24, 2011              “Hand Hygiene Resources

March 2012                 “Human Factors and Operating Room Safety

July 2012                    “A Culture of Disrespect

July 2013                    “"Bad Apples" Back In?

July 22, 2014              “More on Operating Room Briefings and Debriefings

October 7, 2014          “Our Take on Patient Safety Walk Rounds

July 7, 2015                “Medical Staff Risk Issues

September 22, 2015    “The Cost of Being Rude

May 2016                    “ECRI Institute’s Top Ten Patient Safety Concerns for 2016

June 28, 2016             “Culture of Safety and Catheter-Associated Infections

April 2017                   “Relation of Complaints about Physicians to Outcomes

April 2017                   “Joint Commission Sentinel Event Alert on Safety Culture

October 2, 2018          “Speaking Up About Disruptive Behavior

 

 

 

References:

 

 

Riskin A, Erez A, Foulk TA, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics 2015; 136: 487-495

http://pediatrics.aappublications.org/content/136/3/487.abstract

 

 

Riskin A, Bamberger P, Erez A, et al. Incivility and Patient Safety: A Longitudinal Study of Rudeness, Protocol Compliance, and Adverse Events. Joint Commission Journal on Quality and Patient Safety 2019; 45(5): 358-367

https://www.jointcommissionjournal.com/article/S1553-7250(18)30403-3/fulltext

 

 

Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety Published Online First: 31 May 2019

https://qualitysafety.bmj.com/content/early/2019/05/31/bmjqs-2019-009598

 

 

Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. JAMA Surg. Published online July 10, 2019

https://jamanetwork.com/journals/jamasurgery/article-abstract/2738043

 

 

Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg 2019; Published online June 19, 2019

https://jamanetwork.com/journals/jamasurgery/fullarticle/2736337?guestAccessKey=5bc0bbc7-9062-44e6-9c45-94eec1829251&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=061919

 

 

Emerel LV, Kent T, Chu D. Time for Changes in the Surgical Community—Promoting Professionalism as #MeToo 2.0. JAMA Surg. Published online June 19, 2019

https://jamanetwork.com/journals/jamasurgery/article-abstract/2736332

 

 

 

 

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