The Operating Theatre journal April 2021

How can Civility in the Operating Theatre be Improved to Enhance Patient Safety?
By Amy L. Whitebrook ODP
Introduction
The operating theatre is a physically isolated environment in which
multidisciplinary practitioners must collaborate to solve high risk
and time-critical problems, demonstrating effective team working
as a key determinant of safety and efficiency (Coe and Gould, 2008).
Despite this, the present research identifies a pervasive issue with
incivility amongst professionals. Bullying in healthcare has been widely
examined, however, incivility is characterised by lower frequency
and intensity (Bambi et al., 2017), and therefore less explicitly
recognisable. Typically, incivility is defined as expressions of disruptive
or destructive behaviour, behaviours with ambiguous intent that yield
negatives outcomes, veiled actions disguised as civility, or the lack
of action including ignorance and isolation (DeMarco, Fawcett and
Mazzawi, 2018). Many formal definitions and listed examples have been
assimilated but are frequently too narrow to encapsulate the breadth
of the concept. As such, any action that undermines a practitioner’s
ability to provide patient care, excluding those who are advocating
for the patient or challenging the system, can be considered uncivil if
cognitively appraised as such (Villafranca et al., 2017). This behaviour
impacts the reputation of the National Health Service (NHS), as the
public’s trust in their practitioner’s proficiency is safeguarded by
displays of prosocial behaviour (Villafranca et al., 2019).
Primarily, eliminating workplace incivility upholds the Universal
Declaration of Human Rights (United Nations, 1948, p. 4-26) articles;
‘(1) recognition of the inherent dignity in all people’, ‘(3) freedom from
discrimination and arbitrary invasions of privacy’, ‘(5) freedom from
degrading treatment’, and ‘(12) freedom from attacks upon honour and
reputation’. However, due to the public-facing nature of healthcare,
incivility transcends the establishment’s responsibility to protect
employees by systemically affecting the patient experience. The human
factors approach adopted from the aviation industry has become
extensively accepted in healthcare and addresses how the individual,
the task, and the environment, intertwine to impact patient outcomes
(Timmons et al., 2015). As such, the review critically examines how
the published literature links practitioners as targets of uncivil actions
incurring psychological harm and depleted mental energy (Clark and
Kenski, 2017) and the escalating probability of conducting iatrogenic
mistakes (Riskin et al., 2015), failing to sustain patient care standards
and inducing a risk of harm or death. To then integrate the fragmented
knowledge already in the public domain, the review subsequently
provides a comprehensive proposal in strategies to improve operating
department civility, specially tailored to the underrepresented role of
the operating department practitioner (ODP), by formulating actionable
recommendations using evidence-based practice.
Prevalence, Sources, and Targets of Incivility
Primary experimental research begins by assessing the prevalence
of incivility in healthcare, which provides the foundation for further
investigations. Bradley et al. (2015) explored doctor’s experiences as
targets of ‘rude, dismissive and aggressive’ communications acted out
by fellow staff members across three NHS trusts. The survey found
that 31% of respondents felt subjected to incivility multiple times per
week, with 49% of these communications originating from adjunct
departments. Likewise, a similar retrospective questionnaire by
Klingberg et al. (2018) measured 77 emergency department physicians’
experiences of in-house incivility, with 36% reporting exposure once
a month, 26% once a quarter, and 20% once a year. Of these, 62% of
respondents defined the source as being from another division during
multidisciplinary consultations or referrals. As the operating room
is a central point of contact for many specialities and pathways, the
findings indicate that the increased amount of wider communication
needed may pertain to higher incivility levels.
A more recent study by Villafranca et al. (2019) asked 134 perioperative
organisations to distribute a questionnaire to a range of anaesthetists,
surgeons, ODPs, theatre nurses, and medical students, exploring
perceived exposure to uncivil actions from colleagues. Questions
were grouped into four domains and a Likert scale categorised replies
by frequency. The results revealed a substantial 97% of respondents
suffered or witnessed disruptive behaviour at least once a year.
However, opposing the findings of both Bradley et al. (2015) and
Klingberg et al. (2018), Villafranca et al. (2019) categorised the types of
disruptive behaviour in descending order as undirected, in-group, outgroup,
and personal. Furthering this theme, a survey by Coe and Gould
(2008) sent to a diverse spectrum of surgeons, theatre nurses, and ODPs
(Part One)
in 37 NHS surgical departments, identified 69% of all incivility as being
instigated by consultant surgeons. As patient awareness of the theatre
environment is the most shielded, reduced perceived accountability of
professional conduct could be presumed (Coe and Gould, 2008). Thus,
the prevalence of increased in-group incivility may be specific to the
operating department itself.
Another premise within the literature is to identify common
targets of uncivil actions. Survey results by Villafranca et al. (2019)
correlated respondent’s socio-demographic information relating the
characteristics of female, young, non-heterosexual, inexperienced, a
nurse by profession, or working in a privately funded clinic, with a
higher level of perceived exposure to incivility. Only 17% of institutions
approached responded, yet this equated to a large sample size of 7,465
individuals. Notably, many of these traits are known to be exposed to
marginalisation in general society (Villafranca et al., 2019), therefore, a
correlation could equally be due to an increasingly susceptible cognitive
appraisal of incivility. Furthermore, it is theorised that roles within the
multidisciplinary team are not explicitly understood; nurses and ODPs
believe their priority is to advocate for the patient, yet surgeons believe
that their goal is to care for them (Coe and Gould, 2008). The unique
and diverse structure of subsequent in-groups within the theatre team
is evidenced to be an interconnected rationale for the increased rate of
incivility, requiring further exploration of associated impacts.
Reasons uncovered for expressing incivility have been associated with
power demonstrations or to unload stress (Klingberg et al., 2018). The
doctors exposed to uncivil exchanges identified by Bradley et al. (2015)
were juniors in 43%, registrars in 38%, and consultants in just 18% of
cases. Comparably, the main targets of disruptive behaviours in the
operating theatre as identified by Keller et al. (2019) were registrars
or scrub practitioners. The research both indicates seniority as a
protective characteristic against enduring uncivil actions and presents
a hierarchical pattern of initiation and exposure (Bradley et al., 2015).
The task of surgery means that the most complex and demanding
responsibilities naturally fall to the surgeon, therefore, envisioning a
disconnection of the professional process from interpersonal conduct
may be the key to creating harmony within the team structure.
Causes of uncivil communications are also a common area of focus
within the body of published research, with Coe and Gould (2008)
identifying them as the over-running of operations, changes to the order
of the operating lists, and lack of staff and equipment. Endorsing Coe
and Gould (2008) but reducing convenience sampling and self-reporting
bias, an observational investigation by Keller et al. (2019) monitored
operating theatre team communications over 137 elective abdominal
surgeries, in which 340 tense exchanges were witnessed. This equated
to 2.48 per operation, however, varied by 24.01% depending on the lead
surgeon. The main trigger of these unpleasantries was largely found
to be due to coordination problems in 72% of incidences. However,
causation is not determined by the authors’ findings, as verbal tensions
could as credibly be the trigger for, rather than the result of, poor
handling of organisational issues. Supporting this concept, a simulated
emergency major haemorrhage scenario by Katz et al. (2019) assigned
anesthesiology trainees to either an experimental or control group of a
rude or a neutral surgeon, respectively. Independent anesthesiologists
then scored the trainees, yet neither were covertly informed of the
purpose of the study. The findings identified that 91.2% of trainees in
the control group performed at the level expected of them, compared
to just 63.6% in the experimental group. Binary logistic regression
discovered incivility to be the only item that negatively predicted
poorer participant performance. Therefore, the authors were able
to definitively demonstrate a direct line of causality. However, when
contrasted with the real-life scenario used by Keller et al. (2019),
participants of the study by Katz et al. (2019) had no previous working
relationship, which could have arguably skewed the data set.
On reflection of this primary survey of the evidence, a common tangent
found was that surgeons are often held accountable for a large extent of
the incivility in operating theatres. This was not unforeseen, yet being
based largely on survey data, generalisability is poor. Although it is
claimed that the surgical profession attracts individuals with an intense
persona (Page, 2011), to blanket an entire vocation with a distinct
personality is unwarranted. Fundamental attribution error argues
that people psychologically underestimate situational reasonings for
behaviour while exaggerating personality-based explanations (Klein,
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