Hospitals and medical centers are increasingly beginning to appreciate that disruptive behavior in the operating room (OR) is a problem deserving of serious attention. The costs associated with incivility in the OR can be substantial, oftentimes leading to increased staff sick days and decreased nursing retention, both of which are associated with medication errors. Exposure to incivility among surgeons often begins in their formative years. Frequently, perpetrators of belittlement or harassment are residents, fellows, and clinical professors, the same people who serve as role models for the next generation of physicians.
The Perils of Incivility in Surgery
Incivility can lead to social isolation or exclusion, the devaluation of someone else’s work, verbal threats, and even physical confrontations. Furthermore, research shows that rude behavior is bad for both mental and physical health. Conversely, other studies have demonstrated that civil behavior within the workplace can lead to a “helper’s high,” in which others in the OR feel empowered and contribute to improving outcomes in the patients they treat. The challenge for those entrusted with teaching the next generation of surgeons is to nurture the important surgical traits of ego strength, confidence, focus, work ethic, and dedication without forgetting the need to be committed to being civil to each other. Surgeons are people in the position of power who are typically hired on the basis of their knowledge, training, and technical accomplishments. ORs, however, are social environments where everyone must work together for the patients’ benefit.
Fostering Civility in Surgery
To establish a positive OR culture, increased emphasis should be placed on non-technical skills, such as leadership, communication, teamwork, and situational awareness. By not insisting that we make all the decisions and by empowering others to lead, we can gain respect and loyalty among peers and subordinates. A “top-down” management strategy was prevalent among surgical leaders 20 or 30 years ago, but this approach is now out of style. There are three key strategies for improving the behavioral culture in ORs:
1. Recognize the power of civility. Civility has the potential to improve the surgical workplace, patient outcomes, and workers’ quality of life. Developing a clear, consistent code for all staff—regardless of stature within the organization— is paramount.
2. Eliminate anonymity. To foster civility, the staff needs to know each other. The rewards from becoming acquainted with coworkers are substantial. As anonymity dissipates, it’s less likely that rude behaviors will be initiated or accepted. Minor disagreements can stay minor rather than escalate into damaging conflicts. When recruiting staff, trainees, and faculty, assess social skills and personality traits that will nurture a culture of civility.
3. Get leadership “buy-in.”Administrative leaders should help model the behavioral culture for the team working in the OR. The training methods used to shape the next generation of surgeons should encourage the advancement of knowledge and the promotion of good surgical judgment while keeping a keen eye on commitment to civility.
A Great Opportunity
The surgical community has an incredible opportunity to lead a civility initiative in healthcare. We must remember that today’s victims are tomorrow’s bullies. Developing a fair and consistent universal code for surgeons, nurses, staff, and administrators to foster civility in the OR can yield substantial dividends, promoting trust, respect, and loyalty while also creating a positive working environment that is safer and more efficient for the patients we treat.
Readings & Resources (click to view)
Klein AS, Forni PM. Barbers of civility. Arch Surg. 2011;146:774-777. Available at: http://archsurg.ama-assn.org/cgi/content/full/146/7/774.
Waisel DB. Developing social capital in the operating room: the use of population-based techniques. Anesthesiology. 2005;103:1305-1310.
Kerfoot KM. Leadership, civility, and the ‘no jerks’ rule. Urol Nurs. 2008;28:149-150.
Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005;105:54-65.
Kivimäki M, Elovainio M, Vahtera J. Workplace bullying and sickness absence in hospital staff. Occup Environ Med. 2000;57:656-660.
Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197:678-685.