The Operating Theatre journal April 2021

2017), which could give a differing dynamic to how such findings are
analysed. Likewise, the results are reliant on the respondent’s memory
recall and subjective interpretation of events. Nonetheless, incivility’s
existence is bound to human perceptual processing (Kerber et al.,
2015), and so a purely objective study would be decontextualized
and unfeasible to achieve. Additionally, the anonymous freedom
of participation in voluntary surveys works to uphold ethical
responsibilities, by diminishing the possibility of personal psychological
harm relating to recollecting negative events (Villafranca et al., 2019).
Impacts of Incivility on the Individual and the Team
Incivility poses a threat to personal standing, with practitioners
affected experiencing psychological manifestations such as reduced
self-esteem, anxiety, and occupational depression (DeMarco, Fawcett
and Mazzawi, 2018). This can then advance into physical symptoms
including headaches and high blood pressure (DeMarco, Fawcett and
Mazzawi, 2018). Equally, maladaptive coping mechanisms have been
linked to polluting a practitioner’s home-life by reduced quality of sleep,
dysfunctional personal relationships, and substance abuse (Villafranca
et al., 2017). At its core, incivility impacts on an individual level; all
other repercussions of disruptive behaviours are a compounded causal
sequence of events (DeMarco, Fawcett and Mazzawi, 2018). A crosssectional
survey by Shi et al. (2018) of 696 new nurses’ experiences
discovered by a linear regression model that incivility positively
predicted anxiety, which ultimately caused professional burn-out, yet
resilience acted as a moderating factor. The study had a notable 77%
response rate; however, practitioners were asked to complete the
questionnaire on a mobile device during rest breaks, in which fatigue
could have impaired their cognitive decision-making process. The
authors’ conclusive recommendations for practice necessitated further
training should be undertaken to improve practitioners ‘emotional
toughness’, but arguably, this goes against the core values desired
of healthcare professionals. The data collected by Shi et al. (2018)
was then used by Zhang et al. (2018) to perform an additional linear
regression model, which identified that incivility negatively impacted
perceived job performance, with high career expectations acting as a
buffer. Using a distinct set of data for a new analysis is questionable
as the study omits if the second examination was consented for by
the respondents, but together the studies highlight a pertinent primary
issue in the mental energy that navigating incivility consumes.
Uncivil behaviour causes a shift in the practitioner’s attention, moving
from being focused on the task at hand to homing in on the perpetrator’s
actions (Riskin et al., 2019). This has been linked to reduced working
memory and situational awareness, leading to poorer co-ordination
and team working in the operating theatre (Keller et al., 2019). In an
experiment by Riskin et al. (2015), 72 diverse neonatal healthcare
professionals were randomly allocated into 2 groups and attended
an emergency scenario simulation, in which the observer acted
rudely or neutrally. A multivariate analysis of the results identified
both diagnostic and procedural team performance was negatively
affected by rudeness, with help-seeking and information sharing as
mediating factors. Although external validity to a real-world situation
is questionable when using simulations, the variable suggests only an
underestimate in the impact incivility could have on a genuine crisis.
This is evidenced in a similar study by Katz et al. (2019), in which 76
trainee anesthesiologists were randomly assigned to an experimental
or control group of a rude or neutral surgeon as they attended a major
haemorrhage scenario. The results found that 91% of trainees in the
control group performed at the level expected of them, compared to
only 64% in the experimental group. A binary logistic regression model
identified incivility as the only item that negatively affected participant
performance, with trainee scores impacted in the domains of decision
making, vigilance, communication, and teamwork. Ultimately, such
experiments using a role-play are likely to give the utmost achievable
data, as the direct influence on the patient’s care would make true-life
situations unethical and immoral to manipulate.
The results of the above studies pose some gaps in the literature; a
failure to examine situations in which a team are familiar with each
other, the Hawthorne effect of being observed (Landsberger, 1958),
any follow up on the ethical consideration relating to psychological
repercussions of negative scenario experiments, and the limited
investigations specific to practice in the United Kingdom (UK). This
makes extrapolation of the effects of incivility trust-wide difficult
to predict, however, the application of single study results across a
multitude of environments is never recommended. Incivility is an issue
that fundamentally impacts first at a personal level (DeMarco, Fawcett
and Mazzawi, 2018), therefore, considering each article independently
provides valuable insight into a focused area of practice. The depth
of this understanding does not need to apply to a whole community
to uphold its significance; all experimental research results are
constricted to the encapsulated situation, and regardless of its calibre,
further trials will always need to be conducted before organisational
approval is given to adjust practice (Bennett et al., 2012).
Consequences of Incivility on Patient Safety
The mental state of depletion associated with a practitioner’s
experience as a target of incivility undoubtedly impacts optimum
decision making, which increases the likelihood of iatrogenic mistakes
(Riskin et al., 2019). This is evidenced by Riskin et al. (2019), in which
160 physicians and nurses from across 18 hospital departments in the
United States of America (USA), were asked to respond to questions
using a smartphone application at 2 points during a single shift. The
first questionnaire measured exposure to incivility, and four hours
later, a second questionnaire measured cognitive resources. Using
multivariate analysis, increased measures of incivility positively
correlated with decreased hand hygiene compliance and increased
reported adverse events, yet these did not reach statistical significance.
However, incorrect medication preparation and reduced information
sharing measures produced a robust association. The study provides
contextual real-time results and recognises the short-term effects of
incivility exposure; though incivility occurs at random and disruptive
events are not limited to the start of a shift, therefore no causal order
can be confirmed. Nonetheless, the intervention holds significance in
broadening the spectrum of concepts in which incivility and patient
safety are entwined.
Expanding the ideology of the impact practitioner incivility has on
patient safety, Woo and Kim (2020) collated 192 questionnaire responses
from nurses in 10 hospitals in Korea, which identified by regression
analysis that incivility negatively impacted compassionate caregiving,
moderated by psychological capital. Compassion, as an awareness of a
patient’s suffering and the desire to help, is a key quality needed by
all healthcare professionals to uphold safety standards (Woo and Kim,
2020). As previously established, exposure to incivility decreases mental
wellness (DeMarco, Fawcett and Mazzawi, 2018), thus, psychological
capital is reduced, affecting the practitioner’s ability to sensitively
responded to another person’s needs. As such, Woo and Kim (2020) fail
to identify that increasing psychological capital to mediate the effect
of incivility is a cause-and-effect dilemma. Subsequently, Porath and
Erez (2009) during an observational study, identified that watching
rudeness directed at another stimulates a social contagion, in which
witnesses are affected comparably to the victim. Consequently, the
wider impact evidenced by the literature reveals how incivility breeds
further incivility, with the quality of the patient’s care at the end of
each chain of events.
Studies such as Riskin et al. (2019) and Woo and Kim (2020) rely heavily
on self-reporting methods, underpinned by practitioner’s honesty
in upholding their ethical responsibility not to hinder patient safety.
This presents one of the fundamental problems in highlighting the
consequences of incivility on patient safety as cognitive appraisal.
Namely, Rosenstein and O’Daniel (2006) surveyed 244 practitioners,
including surgeons, nurses, anesthesiologists, surgical technologists,
and operating room assistants in the USA, and found that 94% of
respondents believed disruptive behaviour could have a negative
influence on patient safety. When asked if they were aware of any such
event that could have seriously impacted the patient, 62% responded
yes, with 80% stating they believed any adverse outcome would have
been preventable. However, when lastly questioned as to whether they
could recall being involved in or witnessing a specific disruptive event
that compromised patient care, only 19% of participants answered
yes. The low percentage results of the final question may be due to
answering truthfully becoming a progressively more difficult task, as
feelings associated with being the victim of incivility can begin in the
subconscious, are often fluid in nature, and pose damage to the ego
(Vahle-Hinz, 2019). This evidences that the respondent needs to be
able to interpret the sensory information obtained from an event and
then accept a place in the causal sequence for accurate reports to be
obtained. Until there is a break in the system; awareness of the negative
effects of incivility is commonplace and accountability is upheld, the
research could be stuck in a recurring cycle of underreporting then
underreacting.
References are included with Part two.
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