Rudeness and Medical Team Performance

Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review

Background

Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems.

Aim

To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them.

Methods

Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines.

Data sources

Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022.

Results

Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models.

Conclusions

Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations.

Future work

Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues.

Limitations

This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care.

Study registration

This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

Satisfaction with clinical pathway implementation versus job performance of clinicians: empirical evidence on the mediating role of work engagement from public hospitals in Sichuan, China

BACKGROUND

The job performance of clinicians is a clear indicator of both hospital capacity and the level of hospital service. It plays a crucial role in maintaining the effectiveness and quality of medical care. Clinical pathways are a systematic method of quality improvement successfully recommended by broader healthcare systems. Since clinicians play a key role in implementing clinical pathways in public hospitals, this study aims to investigate the effect of the satisfaction of clinicians in public hospitals with clinical pathway implementation on their job performance.

METHODS

A cross-sectional study design was used. Questionnaires were administered online. A total of 794 clinicians completed the questionnaires in seven tertiary public hospitals in Sichuan Province, China, of which 723 were valid for analysis. Questionnaires contained questions on social demographic characteristics, satisfaction with clinical pathway implementation, work engagement, and job performance. Structural Equation Model (SEM) was used to test the hypotheses.

RESULTS

The satisfaction of clinicians in public hospitals with clinical pathway implementation was significantly positively correlated with work engagement (r = 0.570, P < 0.01) and job performance (r = 0.522, P < 0.01). A strong indirect effect of clinicians' satisfaction with clinical pathway implementation on job performance mediated by work engagement was observed, and the value of this effect was 0.383 (boot 95%CI [0.323, 0.448]).

CONCLUSION

The satisfaction of clinicians in public hospitals with clinical pathway implementation not only directly influences their job performance, but also indirectly affects it through the mediating variable of work engagement. Therefore, managers of public hospitals need to pay close attention to clinicians' evaluation and perception of the clinical pathway implementation. This entails taking adequate measures, such as providing strong organizational support and creating a favorable environment for the clinical pathway implementation. Additionally, focusing on teamwork to increase clinicians' satisfaction can further enhance job performance. Furthermore, managers should give higher priority to increasing employees' work engagement to improve clinicians' job performance.

Psychological safety in the perioperative environment: a cost-consequence analysis

INTRODUCTION

Psychologically unsafe healthcare environments can lead to high levels of staff turnover, and unwanted financial burden. In this study, we investigate the hypothesis that lower levels of psychological safety are associated with higher levels of turnover, within an anaesthesiology department and we estimate the cost attributable to low psychological safety, driven by turnover costs.

METHODS

Psychological safety was measured in one academic department. The psychological safety score was correlated with 'intention to leave' using linear regression and Pearson correlation and a cost-consequence analysis was performed.

RESULTS

One hundred and thirty-eight physician anaesthesiologists (MDs) and 282 certified registered nurse anaesthetists (CRNAs) were surveyed. The response rate was 67.4% (93/138) for MDs and 60.6% (171/282) for CRNAs. There was an inverse relationship between psychological safety and turnover intent for both MDs (Pearson correlation -0.373, p value <0.0002) and CRNAs (Pearson correlation -0.486, p value <0.0002). The OR of intent to turn over in the presence of low psychological safety was 6.86 (95% CI 1.38 to 34.05) for MDs and 8.93 (95% CI 4.27 to 18.68) for CRNAs. The cost-consequence analysis demonstrated the cost of low psychological safety related to turnover per year was $337, 428 for MDs and $14, 024, 279 for CRNAs. Reducing low psychological safety in CRNAs from 31.6% to 20% reduces the potential cost of low psychological to $8 876 126.03.

CONCLUSION

There is a cost relationship between low psychological safety and turnover. Low psychological safety in an academic anaesthesiology department may result in staff turnover, and potentially high financial costs.

Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review

BACKGROUND

Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB.

METHODS

A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.

RESULTS

We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust.

CONCLUSION

Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB.

STUDY REGISTRATION

This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Eyes on incivility in surgical teams: Teamwork, well-being, and an intervention

Incivility in surgery is prevalent and negatively impacts effectiveness and staff well-being. The purpose of this study was to a) examine relationships between incivility, team dynamics, and well-being outcomes, and b) explore a low-cost intervention of 'eye' signage in operating theater areas to reduce incivility in surgical teams. A mixed methods design was used in an orthopedic hospital. Surveys of incivility, teamwork, and well-being were administered three months apart in a small private hospital. An intervention of signage with eyes was placed in the theater area after administration of the first survey, using a pretest-posttest design. Participants also responded to an open-ended question about suggestions for improvements at the end of the survey which was then thematically analyzed. At the individual level (n = 74), incivility was statistically significantly related to team dynamics which in turn was significantly related to burnout, stress, and job attitudes. At the aggregate level, reported incivility was statistically significantly lower after the 'eye' sign intervention. Thematic analysis identified core issues of management behaviors, employee appreciation, communication, and work practices. Incivility in surgical teams has significant detrimental associations with burnout, stress, and job attitudes, which occurs through its impact on decreased team dynamics and communication. A simple intervention that evokes perceptions of being observed, such as signage of eyes in theater areas, has the potential to decrease incivility at least in the short term, demonstrating that incivility is amenable to being modified. Additional research on targeted interventions to address incivility are needed to improve teamwork and staff well-being.

Hospital staff reports of coworker positive and unprofessional behaviours across eight hospitals: who reports what about whom?

BACKGROUND

Workplace behaviours of healthcare staff impact patient safety, staff well-being and organisational outcomes. A whole-of-hospital culture change programme, Ethos, was implemented by St. Vincent's Health Australia across eight hospitals. Ethos includes a secure online submission system that allows staff across all professional groups to report positive (Feedback for Recognition) and negative (Feedback for Reflection) coworker behaviours. We analysed these submissions to determine patterns and rates of submissions and identify the coworker behaviours reported.

METHOD

All Ethos submissions between 2017 and 2020 were deidentified and analysed. Submissions include structured data elements (eg, professional role of the reporter and subjects, event and report dates) and a narrative account of the event and coworker behaviours. Descriptive statistics were calculated to assess use and reporting patterns. Coding of the content of submissions was performed to classify types of reported coworker behaviours.

RESULTS

There were a total of 2504 Ethos submissions, including 1194 (47.7%) Recognition and 1310 (52.3%) Reflection submissions. Use of the submission tool was highest among nurses (20.14 submissions/100 nursing staff) and lowest among non-clinical services staff (5.07/100 non-clinical services staff). Nurses were most frequently the subject of Recognition submissions (7.56/100 nurses) while management and administrative staff were the least (4.25/100 staff). Frequently reported positive coworker behaviours were non-technical skills (79.3%, N=947); values-driven behaviours (72.5%, N=866); and actions that enhanced patient care (51.3%, N=612). Medical staff were the most frequent subjects of Reflection submissions (12.59/100 medical staff), and non-clinical services staff the least (4.53/100 staff). Overall, the most frequently reported unprofessional behaviours were being rude (53.8%, N=705); humiliating or ridiculing others (26%, N=346); and ignoring others' opinions (24.6%, N=322).

CONCLUSION

Hospital staff across all professional groups used the Ethos messaging system to report both positive and negative coworker behaviours. High rates of Recognition submissions demonstrate a strong desire of staff to reward and encourage positive workplace behaviours, highlighting the importance of culture change programmes which emphasise these behaviours. The unprofessional behaviours identified in submissions are consistent with behaviours previously reported in surveys of hospital staff, suggesting that submissions are a reliable indicator of staff experiences.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process

OBJECTIVES

Achieving diagnostic excellence on medical wards requires teamwork and effective team dynamics. However, the study of ward team dynamics in teaching hospitals is relatively underdeveloped. We aim to enhance understanding of how ward team members interact in the diagnostic process and of the underlying behavioral, psychological, and cognitive mechanisms driving team interactions.

METHODS

We used mixed-methods to develop and refine a conceptual model of how ward team dynamics in an academic medical center influence the diagnostic process. First, we systematically searched existing literature for conceptual models and empirical studies of team dynamics. Then, we conducted field observations with thematic analysis to refine our model.

RESULTS

We present a conceptual model of how medical ward team dynamics influence the diagnostic process, which serves as a roadmap for future research and interventions in this area. We identified three underexplored areas of team dynamics that are relevant to diagnostic excellence and that merit future investigation (1): ward team structures (e.g., team roles, responsibilities) (2); contextual factors (e.g., time constraints, location of team members, culture, diversity); and (3) emergent states (shared mental models, psychological safety, team trust, and team emotions).

CONCLUSIONS

Optimizing the diagnostic process to achieve diagnostic excellence is likely to depend on addressing all of the potential barriers and facilitators to ward team dynamics presented in our model.

Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review

BACKGROUND

Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom.

METHODS

This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories.

RESULTS

Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics.

CONCLUSIONS

Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups.

STUDY REGISTRATION

This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Cognitive Ergonomics: A Review of Interventions for Outpatient Practice

Doctoring is difficult mental work, involving many cognitively demanding processes such as diagnosing, decision-making, parallel processing, communicating, and managing the emotions of others. According to cognitive load theory (CLT), working memory is a limited cognitive resource that can support a finite amount of cognitive load. While the intrinsic cognitive load is the innate load associated with a task, the extraneous load is generated by inefficiency or suboptimal work conditions. Causes of extraneous cognitive load in healthcare include inefficiency, distractions, interruptions, multitasking, stress, poor communication, conflict, and incivility. High levels of cognitive load are associated with impaired function and an increased risk of burnout among physicians. Cognitive ergonomics is the branch of human factors and ergonomics (HFE) focused on supporting the cognitive processes of individuals within a system. In health care, where the cognitive burden on physicians is high, cognitive ergonomics can establish practices and systems that decrease extraneous cognitive load and support pertinent cognitive processes. In this review, we present cognitive ergonomics as a useful framework for conceptualizing an oft-overlooked dimension of labor and apply theory to practice by summarizing evidence-based cognitive ergonomics interventions for outpatient care settings. Our proposed interventions are structured within four general recommendations: 1. minimize distractions, interruptions, and multitasking; 2. optimize the use of the electronic health record (EHR); 3. optimize the use of health information systems (HIS); and 4. support good communication and teamwork. Best practices in cognitive ergonomics can benefit patients, minimize practice inefficiency, and support physician career longevity.

Retrospective analysis of factors influencing the implementation of a program to address unprofessional behaviour and improve culture in Australian hospitals

BACKGROUND

Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers.

METHOD

Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers.

RESULTS

Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool ('Design quality and packaging'), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos ('Goals and Feedback', 'Access to Knowledge and Information'). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers.

CONCLUSION

Aspects of the inner setting (e.g., 'Leadership Engagement', 'Tension for Change') had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

Kindness Isn't Just about Being Nice: The Value Proposition of Kindness as Viewed through the Lens of Incivility in the Healthcare Workplace

The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviors, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modeling positive behaviors as well as the deterrence of negative behaviors, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.

When Patient Rudeness Impacts Care: A Review of Incivility in Healthcare

Healthcare workers increasingly face incivility and rude behaviors from patients, families, and visitors. Although these are less severe than other types of mistreatment, studies have documented that they may still impact healthcare worker well-being and patient care. Defining and measuring incivility can be challenging because current research relies on the perceptions of the targets. Furthermore, there is often overlap among different types of mistreatment, and much of it goes unreported by those who experience it. Nevertheless, multiple studies have documented that incivility is common in healthcare and has been associated with burnout and intent to leave. In clinical settings, multiple consequences for patient care have been documented, including adverse consequences in the diagnostic and intervention performance of teams, as well as team processes. One theory is that incivility incidents divert cognitive resources away from the intervention and that these experiences may interfere with higher-order reasoning. Although limited research has been performed in the areas of prevention, response to incidents of incivility, and best practices for ameliorating the effects of incivility, some promising interventions have been reported in the literature.

From a Culture of Incivility to Virtuousness: A Call to Elevate Workplace Behaviors in Radiology

Radiology has been identified as a subspecialty with exceptionally high rates of incivility among colleagues. Such behaviors are detrimental to the well-being, productivity, and retention of health care practitioners and to the quality of patient care. Addressing incivility has become imperative given current and anticipated staff shortages, yet research from positive organizational scholarship suggests a greater opportunity to be had. Going forward, we need not only to address incivility but also to build purpose-driven, compassionate, and supportive workplaces.

The impact of interprofessional incivility on medical performance, service and patient care: a systematic review

The stressful nature of the medical profession is a known trigger for aggression or abuse among healthcare staff. Interprofessional incivility, defined as low-intensity negative interactions with ambiguous or unclear intent to harm, has recently become an occupational concern in healthcare. While incivility in nursing has been widely investigated, its prevalence among physicians and its impact on patient care are poorly understood. This review summarises current understanding of the effects of interprofessional incivility on medical performance, service and patient care. A structured search and screening of literature returned 13 studies of diverse origin, methodology, quality, size and population type. The consensus is that interprofessional incivility is common among physicians and nurses and has both psychological and clinical outcomes, resulting in stress, compromised patient safety and poor quality of care. Junior staff are affected more often than consultants, with higher rates in radiology, general surgery, neurosurgery and cardiology. Incivility also undermines medical team performance, particularly in perioperative settings. In patient care, incivility is associated with complications, medical errors, mortality, and compromised patient safety and quality of care. Patients whose surgeons have a record of incivility can be at higher risk of complications. The impact of incivility on medical performance, service and patient care appears systemic and must be addressed accordingly. This analysis was limited by the methodological weaknesses of the included studies, which highlights the need for more high-quality empirical research. This would benefit the NHS and other stakeholders when designing targeted interventions. In particular, establishing quantitative methods for identifying and measuring incivility will be crucial for improving our understanding of the phenomenon.

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies

The objective of this paper is to explore sources of diagnostic error in musculoskeletal oncology and potential strategies for mitigating them using case examples. As musculoskeletal tumors are often obvious, the diagnostic errors in musculoskeletal oncology are frequently cognitive. In our experience, the most encountered cognitive biases in musculoskeletal oncologic imaging are as follows: (1) anchoring bias, (2) premature closure, (3) hindsight bias, (4) availability bias, and (5) alliterative bias. Anchoring bias results from failing to adjust an early impression despite receiving additional contrary information. Premature closure is the cognitive equivalent of "satisfaction of search." Hindsight bias occurs when we retrospectively overestimate the likelihood of correctly interpreting the examination prospectively. In availability bias, the radiologist judges the probability of a diagnosis based on which diagnosis is most easily recalled. Finally, alliterative bias occurs when a prior radiologist's impression overly influences the diagnostic thinking of another radiologist on a subsequent exam. In addition to cognitive biases, it is also important for radiologists to acknowledge their feelings when making a diagnosis to recognize positive and negative impact of affect on decision making. While errors decrease with radiologist experience, the lack of application of medical knowledge is often the primary source of error rather than a deficiency of knowledge, emphasizing the need to foster clinical reasoning skills and assist cognition. Possible solutions for reducing error exist at both the individual and the system level and include (1) improvement in knowledge and experience, (2) improvement in clinical reasoning and decision-making skills, and (3) improvement in assisting cognition.

The Effects of Rudeness on NICU Medical Teams Studied by a New Tool for the Assessment of Decision-Making Group Dynamics

BACKGROUND

Group decision-making can be placed on a continuum of group dynamics, between Groupthink and Polythink.

OBJECTIVE

To present a new assessment tool for the characterization of medical teams' decision-making group dynamics, and test it to study the effects of exposure to rudeness on various types of group dynamics.

METHODS

Three judges who watched videotapes of critical care simulations evaluated 24 neonatal intensive care unit teams' decision-making processes. Teams were rated using the new assessment tool, especially designed for this quantitative study, based on items adapted from symptoms of Polythink and Groupthink.

RESULTS

Measures of reliability, inter-rater agreement and internal consistency, were reasonably good. Confirmatory factor analysis refined the tool and verified that the symptoms in each category (Polythink or Groupthink) of the refined 14 items' assessment tool were indeed measures of the construct. The average General Score was in the range of the balanced dynamic on the continuum, and without tendency towards one of the extremities (Groupthink or Polythink). No significant effect of exposure to rudeness on group dynamics was found.

CONCLUSIONS

This is a first attempt at using quantitative methods to evaluate decision-making group dynamics in medicine, by adapting symptoms of Groupthink and Polythink as items in a structured assessment tool. It suggests a new approach to understanding decision-making processes of medical teams. The assessment tool seems to be a promising, feasible and reasonably reliable research tool to be further studied in medicine and other disciplines engaged in decision-making.

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic

A survey administered to staff at five hospitals investigated changes in unprofessional behaviour, teamwork and co‐operation during the COVID‐19 pandemic. From 1583 responses, 76.1% (95% confidence interval (CI): 74.0–78.2%) reported no change or a decrease in unprofessional behaviours. Across all professional groups, 43.6% (n = 579, 95% CI: 41.0–46.3%) reported improvements in teamwork and co‐operation. Findings suggest that intensifying work demands, such as those resulting from the pandemic, are not a major trigger for unprofessional behaviour, and root causes lie elsewhere.

Affective influences on clinical reasoning and diagnosis: insights from social psychology and new research opportunities

Psychological research consistently demonstrates that affect can play an important role in decision-making across a broad range of contexts. Despite this, the role of affect in clinical reasoning and medical decision-making has received relatively little attention. Integrating the affect, social cognition, and patient safety literatures can provide new insights that promise to advance our understanding of clinical reasoning and lay the foundation for novel interventions to reduce diagnostic errors and improve patient safety. In this paper, we briefly review the ways in which psychologists differentiate various types of affect. We then consider existing research examining the influence of both positive and negative affect on clinical reasoning and diagnosis. Finally, we introduce an empirically supported theoretical framework from social psychology that explains the cognitive processes by which these effects emerge and demonstrates that cognitive interventions can alter these processes. Such interventions, if adapted to a medical context, hold great promise for reducing errors that emerge from faulty thinking when healthcare providers experience different affective responses.

Teamwork in Pediatric Resuscitation: Training Medical Students on High-Fidelity Simulation

BACKGROUND

Simulation training and teamwork for medical students are essential to improve performance in pediatric cardiopulmonary resuscitation.

PURPOSE

To evaluate if a specific approach to teamwork improves technical and nontechnical performance.

METHODS

We performed quasiexperimental, prospective, pre- and postinterventional, and nonrandomized research with 65 students in the fourth year of their medicine course. This was a case-control study in which teams used a customized TeamSTEPPS protocol (n=34) or not (n=31) for cardiopulmonary arrest training in children using high-fidelity simulation. All participants answered a sociodemographic and satisfaction questionnaire and underwent theory and practice pre- and posttesting. The survey data were collected in 2019 and analyzed using χ², Mann-Whitney, κ, and Wilcoxon tests. p<0.05 was considered significant.

RESULTS

Intervention and control groups achieved better scores in theory posttesting (p<0.001 and p=0.049), but there was no difference between them in pre- (p=0.291) and posttesting (p=0.397). In the checklist of the practice test, all groups obtained their best outcomes in posttesting and the intervention group achieved higher scores (p<0.001). All groups increased the number of teamwork events and reduced the time span to perform resuscitation first steps (p<0.001) in posttesting.

CONCLUSION

The use of teamwork training based on a customized TeamSTEPPS protocol improved performance in team behavior and group technical achievement. The evaluation of the students about the training was positive.

Workplace bullying and team performance: the mediating role of team psychological contract breach

Purpose

This paper aims to examine the relationship between workplace bullying (WPB) and team performance (TP). And it also attempts to investigate the mediating role of team psychological contract breach (TPCB) in the relationship between WPB and TP.

Design/methodology/approach

Multiple sources and a time-lagged approach were applied at six-week intervals to 64 work teams across 12 different firms in Turkey to test the hypotheses. A linear regression analysis was conducted to evaluate the association between variables.

Findings

The results indicate that WPB leads to negative perceptions of TPCB, which, in turn, have a negative impact on TP.

Research limitations/implications

This study design cannot establish causality, in spite of the fact that the authors used time-lagged data to decrease common method bias.

Practical implications

Managers or team leaders can design activities or programs (i.e. counselling sessions) to promote group cohesiveness, as well as immediately address complaints from team members who feel aggrieved to counteract the negative effects of bullying and reprimand perpetrators; such actions can mitigate perceptions of psychological contract breach.

Originality/value

Few studies have been conducted to test the mediating role of TPCB in the team context. This study stands out as it examines the mediating effect of TPCB in the relationship between WPB and TP. The findings advance the understanding of how WPB could negatively affect TP in a mediation model.

Why do acute healthcare staff engage in unprofessional behaviours towards each other and how can these behaviours be reduced? A realist review protocol

INTRODUCTION

Unprofessional behaviours encompass many behaviours including bullying, harassment and microaggressions. These behaviours between healthcare staff are problematic; they affect people's ability to work, to feel psychologically safe at work and speak up and to deliver safe care to patients. Almost a fifth of UK National Health Service staff experience unprofessional behaviours in the workplace, with higher incidence in acute care settings and for staff from minority backgrounds. Existing analyses have investigated the effectiveness of strategies to reduce these behaviours. We seek to go beyond these, to understand the range and causes of such behaviours, their negative effects and how mitigation strategies may work, in which contexts and for whom.

METHODS AND ANALYSIS

This study uses a realist review methodology with stakeholder input comprising a number of iterative steps: (1) formulating initial programme theories drawing on informal literature searches and literature already known to the study team, (2) performing systematic and purposive searches for grey and peer-reviewed literature on Embase, CINAHL and MEDLINE databases as well as Google and Google Scholar, (3) selecting appropriate documents while considering rigour and relevance, (4) extracting data, (5) and synthesising and (6) refining the programme theories by testing the theories against the newly identified literature.

ETHICS AND DISSEMINATION

Ethical review is not required as this study is a secondary research. An impact strategy has been developed which includes working closely with key stakeholders throughout the project. Step 7 of our project will develop pragmatic resources for managers and professionals, tailoring contextually-sensitive strategies to reduce unprofessional behaviours, identifying what works for which groups. We will be guided by the 'Evidence Integration Triangle' to implement the best strategies to reduce unprofessional behaviours in given contexts. Dissemination will occur through presentation at conferences, innovative methods (cartoons, videos, animations and/or interactive performances) and peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021255490.

Creating a culture of safety and respect through professional accountability: case study of the Ethos program across eight Australian hospitals

Behaviour that is disrespectful towards others occurs frequently in hospitals, negatively impacts staff, and may undermine patient care. Professional accountability programs may address unprofessional behaviour by staff. This article examines a whole-of-hospital program, Ethos, developed by St Vincent's Health Australia to address unprofessional behaviour, encourage speaking up, and improve organisational culture. Ethos consists of a bundle of tools, training, and resources, including an online system where staff can make submissions regarding their co-workers' exemplary or unprofessional behaviour. Informal feedback is provided to the subject of the submission to recognise or encourage reflection on their behaviour. Following implementation in eight St Vincent's Health Australia hospitals, the Ethos Messaging System has had 2497 submissions, 54% about positive behaviours. Peer messengers who deliver 'Feedback for Reflection' have faced practical challenges in providing feedback. Guidelines for the team who 'triage' Ethos messages have been revised to ensure only feedback that will promote reflection is passed on. Early evidence suggests Ethos has positively impacted staff, although evaluation is ongoing. The COVID-19 pandemic has required some adaptations to the program.

Incivility Is Rising Among American Politicians on Twitter

We provide the first systematic investigation of trends in the incivility of American politicians on Twitter, a dominant platform for political communication in the United States. Applying a validated artificial intelligence classifier to all 1.3 million tweets made by members of Congress since 2009, we observe a 23% increase in incivility over a decade on Twitter. Further analyses suggest that the rise was partly driven by reinforcement learning in which politicians engaged in greater incivility following positive feedback. Uncivil tweets tended to receive more approval and attention, publicly indexed by large quantities of “likes” and “retweets” on the platform. Mediational and longitudinal analyses show that the greater this feedback for uncivil tweets, the more uncivil tweets were thereafter. We conclude by discussing how the structure of social media platforms might facilitate this incivility-reinforcing dynamic between politicians and their followers.

An exploratory survey study of disorder and its association with safety culture in four hospitals

Background

Signs of disorder in neighbourhoods (e.g., litter, graffiti) are thought to influence the behaviour of residents, potentially leading to violations of rules and petty criminal behaviour. Recently, these premises have been applied to the hospital context, with physical and social disorder found to have a negative association with patient safety. Building on these results, the present study investigates whether physical and social disorder differ between hospitals, and their relationship to safety culture.

Methods

We conducted a cross sectional survey with Likert-style and open response questions administered in four Australian hospitals. All staff were invited to participate in the pilot study from May to September 2018. An analysis of variance (ANOVA) was used to examine differences in disorder by hospital, and hierarchical linear regression assessed the relationship of physical and social disorder to key aspects of safety culture (safety climate, teamwork climate). Open responses were analysed using thematic analysis to elaborate on manifestations of hospital disorder.

Results

There were 415 survey respondents. Significant differences were found in perceptions of physical disorder across the four hospitals. There were no significant differences between hospitals in levels of social disorder. Social disorder had a significant negative relationship with safety and teamwork climate, and physical disorder significantly predicted a poorer teamwork climate. We identified five themes relevant to physical disorder and four for social disorder from participants’ open responses; the preponderance of these themes across hospitals supported quantitative results.

Conclusions

Findings indicate that physical and social disorder are important to consider in attempting to holistically understand a hospital’s safety culture. Interventions that target aspects of physical and social disorder in a hospital may hold value in improving safety culture and patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07930-6.

Job performance in healthcare: a systematic review

BACKGROUND

Healthcare organisations face major challenges to keep healthcare accessible and affordable. This requires them to transform and improve their performance. To do so, organisations must influence employee job performance. Therefore, it is necessary to know what the key dimensions of job performance in healthcare are and how these dimensions can be improved. This study has three aims. The first aim is to determine what key dimensions of job performance are discussed in the healthcare literature. The second aim is to determine to which professionals and healthcare organisations these dimensions of job performance pertain. The third aim is to identify factors that organisations can use to affect the dimensions of job performance in healthcare.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The authors searched Scopus, Web of Science, PubMed, and Google Books, which resulted in the identification of 763 records. After screening 92 articles were included.

RESULTS

The dimensions - task, contextual, and adaptative performance and counterproductive work behaviour - are reflected in the literature on job performance in healthcare. Adaptive performance and counterproductive work behaviour appear to be under-researched. The studies were conducted in different healthcare organisations and pertain to a variety of healthcare professionals. Organisations can affect job performance on the macro-, meso-, and micro-level to achieve transformation and improvement.

CONCLUSION

Based on more than 90 studies published in over 70 journals, the authors conclude that job performance in healthcare can be conceptualised into four dimensions: task, contextual and adaptive performance, and counterproductive work behaviour. Generally, these dimensions correspond with the dimensions discussed in the job performance literature. This implies that these dimensions can be used for further research into job performance in healthcare. Many healthcare studies on job performance focus on two dimensions: task and contextual performance. However, adaptive performance, which is of great importance in constantly changing environments, is under-researched and should be examined further in future research. This also applies to counterproductive work behaviour. To improve job performance, interventions are required on the macro-, meso-, and micro-levels, which relate to governance, leadership, and individual skills and characteristics.

A Quality Improvement Project to Reduce Events of Visitor Escalation in the Intensive Care Nursery

BACKGROUND

Escalating and aggressive visitor behaviors have become increasingly common in healthcare settings nationally, negatively impacting staff and patients alike. Most healthcare providers do not innately possess the specific skills to manage such behaviors. Management of escalating and aggressive behaviors presents a particularly bedeviling challenge when staff safety must be balanced with the needs of parent-neonate bonding.

PURPOSE

In the Intensive Care Nursery (ICN), the frequency of aggressive and hostile incidents from visitors increased such that the staff felt frustrated by and uneasy about their work environment.

METHODS

The ICN convened an interprofessional team to strategize interventions aimed at consistently managing aggressive behavior and supporting the staff after aggressive and/or hostile visitor encounters.

FINDINGS

Following staff education and training, the unit launched a de-escalation management algorithm in July 2018 that assisted in identifying high-risk families at admission and drove consistent action and management of all visitor behaviors. In the 12 months following the intervention, the frequency of behavioral escalation decreased by 75% and staff perception of safety increased by 25%.

IMPLICATIONS FOR PRACTICE

Collaborating with staff to design consistent strategies to manage aggressive and escalating visitor behavior can improve safety and improve employee satisfaction in the ICN.

IMPLICATIONS FOR RESEARCH

Additional research on the effectiveness of the algorithm in other ICNs and alternative areas of practice is needed. Furthermore, validation of a staff perception survey measuring the impact of escalating visitor behaviors on employees would be an important next step in this research.Video abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=43.

The horizon of pediatric cardiac critical care

Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.

What's Playing in Your Waiting Room? Patient and Provider Stress and the Impact of Waiting Room Media

Patients enter the healthcare space shouldering a lot of personal stress. Concurrently, health care providers and staff are managing their own personalstressors as well as workplace stressors. As stress can negatively affect the patient-provider experience and cognitive function of both individuals, it is imperative to try to uplift the health care environment for all. Part of the healthcare environmental psychology strategy to reduce stress often includes televisions in waiting rooms, cafeterias, and elsewhere, with the intent to distract the viewer and make waiting easier. Although well-intentioned, many select programming which can induce stress (eg, news). In contrast, as positive media can induce desirable changes in mood, it is possible to use it to decrease stress and uplift viewers, including staff. Positive media includes both nature media, which can relax and calm viewers and kindness media, which uplifts viewers, induces calm, and promotes interpersonal connection and generosity. Careful consideration of waiting room media can affect the patient-provider experience.

Emotional Harm in the Radiology Department: Analysis of an Underrecognized Preventable Error

Background Emotional harm incidents in health care may result in lost trust and adverse outcomes. However, investigations of emotional harm in radiology departments remain lacking. Purpose To better understand contributors and clinical scenarios in which emotional harm can occur in radiology, to document incidences, and to develop preventative countermeasures. Materials and Methods A large tertiary hospital adverse event reporting system was retrospectively searched for submissions under the category of dignity and respect in radiology between December 2014 and December 2020. Submissions were assigned to one of 14 categories per a previously developed classification system. Root-cause analysis of events was performed with a focus on countermeasures for future prevention. The person experiencing emotional harm (patient or staff) was noted. Results Of all radiology-related submissions, 37 of 3032 (1.2%) identified 43 dignity and respect incidents: failure to be patient centered (n = 23; 54%), disrespectful communication (n = 16; 37%), privacy violation (n = 2; 5%), minimization of patient concerns (n = 1; 2%), and loss of property (n = 1; 2%). Failure to be patient centered (n = 23) was subcategorized into disregard for patient preference (12 of 23; 52%), delay in care (eight of 23; 35%), and ineffective communication (three of 23; 13%). Of the 43 incidents, 32 involved patients (74%) and 11 involved staff (26%). Emotional harm in staff was because of disrespectful communication from other staff (eight of 11; 73%). Seventy-three countermeasures were identified: staff communication training (n = 32; 44%), individual feedback (n = 18; 25%), system innovation (n = 16; 22%), improvement of existing communication processes (n = 3; 4%), process reminders (n = 3; 4%), and unclear (n = 1; 1%). Individual feedback and staff communication training that focused on active listening, asking for the patient's preferences, and closed-loop communication addressed 34 of the 43 incidents (79%). Conclusion Most emotional harm incidents were from disrespectful communication and failure to be patient centered. Providing training focused on active listening, asking for patient's preferences, and closed-loop communication would potentially prevent most of these incidents. © RSNA, 2021 See also the editorial by Bruno in this issue.

Clinician-family relationships may impact neonatal intensive care: clinicians' perspectives

OBJECTIVE

Collaborative clinician-family relationships are necessary for the delivery of successful patient- and family-centered care (PFCC) in the NICU. Challenging clinician-family relationships may undermine such collaboration and the potential impacts on patient care are unknown.

STUDY DESIGN

Consistent caregivers were surveyed to describe their relationships and collaboration with families of infants hospitalized ≥ 28 days. Medical record review collected infant and family characteristics hypothesized to impact relationships. Mixed methods analysis was performed.

RESULTS

Clinicians completed 243 surveys representing 77 families. Clinicians reported low collaboration with families who were not at the bedside and/or did not speak English. Clinicians perceived most clinician-family relationships impact the infant's hospital course. Negative impacts included communication challenges, mistrust or frustration with the team and disruptions to patient care.

CONCLUSION

This study identifies features of clinician-family relationships that may negatively impact an infant's NICU stay. Targeting supports for these families is necessary to achieve effective PFCC.

How witnessing rudeness can disrupt psycho-motor performance of dental students

Rude and disrespectful behaviors are ubiquitous and pervasive in the workplace. The purpose of this study was to examine the effects of witnessed rudeness on dental student psychomotor performance. Using an experimental, between-subjects design, 71 2nd (Sophomore) year dental students witnessed either an experimental (rude) or control (neutral) condition in which a confederate lab manager interacted in a rude or neutral manner with a prospective lab assistant candidate. Students then performed a mock prosthodontics psychomotor examination as part of the fixed prosthodontics preclinical course. Results indicated that those students who arrived at the experimental session cognitively depleted (+1 SD above the mean) and were exposed to the rude condition were significantly more likely to make critical errors when performing a posterior bridge preparation, compared to those students in the control group. There were no significant differences between the rude and control conditions for participants who were not cognitively depleted (-1 SD below the mean). Overall, the findings indicate that for those dental students suffering from cognitive depletion, merely witnessing rudeness can have adverse impacts on psychomotor performance and potentially, eventual patient care.

Mistaken Identity: Frequency and Effects of Gender-Based Professional Misidentification of Resident Physicians

PURPOSE

Evaluation of the medical profession at all levels has exposed episodes of gender-based role misidentification whereby women physicians are disproportionately misidentified as nonphysicians. The authors of this study investigate this phenomenon and its repercussions, quantifying the frequency with which resident physicians experience role misidentification and the effect this has on their experience and behavior.

METHOD

In 2018, the authors conducted a cross-sectional survey study of internal medicine, surgical, and emergency medicine residents at a single, large, urban, tertiary academic medical center. The survey tool captured both the self-reported frequency and effect of professional misidentification. The authors used a t test and linear multivariate regression to analyze the results.

RESULTS

Of the 260 residents who received the survey, 186 (72%) responded, and the authors analyzed the responses of 182. All 85 of the women respondents (100%) reported being misidentified as nonphysicians at least once in their professional experience by patients or staff members, compared with 49% of the 97 men respondents. Of those 182 residents, 35% of women were misidentified more than 8 times per month by patients compared with 1% of men. Of the 85 women physicians responding to the survey, 38% felt angry and 36% felt less satisfied with their jobs as a result of misidentification compared with, respectively, 7% and 9% of men. In response to role misidentification, 51% of women changed their manner of attire and 81% changed their manner of introduction, compared with, respectively, 7% and 37% of men.

CONCLUSIONS

These survey results demonstrate that women physicians are more likely than men physicians to be misidentified as nonphysicians and that role misidentification provokes gender-polarized psychological and behavioral responses that have potentially important professional ramifications.

Positive communication behaviour during handover and team-based clinical performance in critical situations: a simulation randomised controlled trial

BACKGROUND

Positive communication behaviour within anaesthesia teams may decrease stress response and improve clinical performance. We aimed to evaluate the effect of positive communication during medical handover on the subsequent team-based clinical performance in a simulated critical situation. We also assessed the effect of positive communication behaviour on stress response.

METHODS

This single-centre RCT involved anaesthesia teams composed of a resident and a nurse in a high-fidelity scenario of anaesthesia-related paediatric laryngospasm after a standardised handover. During the handover, similar information was provided to all teams, but positive communication behaviour was adopted only for teams in the intervention group. Primary outcome was team-based clinical performance, assessed by an independent blinded observer, using video recordings and a 0-to 100-point scenario-specific scoring tool. Three categories of tasks were considered: safety checks before the incision, diagnosis/treatment of laryngospasm, and crisis resource management/non-technical skills. Individual stress response was monitored by perceived level of stress and HR variability.

RESULTS

The clinical performance of 64 anaesthesia professionals (grouped into 32 teams) was analysed. The mean (standard deviation) team-based performance score in the intervention group was 44 (10) points vs 35 (12) in the control group (difference: +8.4; CI_95% [0.4-16.4]; P=0.04). The effects were homogeneous over the three categories of tasks. Perceived level of stress and HR variability were not significantly different between groups.

CONCLUSIONS

Positive communication behaviour between healthcare professionals during medical handover improved team-based performance in a simulation-based critical situation.

CLINICAL TRIAL REGISTRATION

NCT03375073.

The effects of rudeness, experience, and perspective-taking on challenging premature closure after pediatric ICU physicians receive hand-off with the wrong diagnosis: a randomized controlled simulation trial

OBJECTIVES

Rudeness exposure has been shown to inhibit diagnostic performance. The effects of rudeness on challenging a handed-off diagnostic error has not been studied.

METHODS

This was a randomized controlled study of attending, fellow, and resident physicians in a tertiary care pediatric ICU. Participants underwent a standardized simulation that started with the wrong diagnosis in hand-off. The hand-off was randomized to neutral vs. rude. Participants were not informed of the randomization nor diagnostic error prior to the simulation. Perspective taking questionnaires were administrated for each participant. Primary outcome was challenging diagnostic error post-simulation. Secondary outcomes included rate and frequency of diagnostic error challenge during simulation.

RESULTS

Among 41 simulations (16 residents, 14 fellows, and 11 attendings), the neutral group challenged the diagnostic error more than the rude group (neutral: 71%, rude: 55%, p=0.28). The magnitude of this trend was larger among resident physicians only, although not statistically significant (neutral: 50%, rude: 12.5%, p=0.11). Experience was associated with a higher percentage of challenging diagnostic error (residents: 31%, fellows: 86%, attendings: 82%, p=0.003). Experienced physicians were faster to challenge diagnostic error (p<0.0003), and experience was associated with a greater frequency of diagnostic error challenges (p<0.0001). High perspective taking scores were also associated with 1.63 times more diagnostic error challenges (p=0.007).

CONCLUSIONS

Experience was strongly associated with likelihood to challenge diagnostic error. Rudeness may disproportionally hinder diagnostic performance among less experienced physicians. Perspective taking merits further research in possibly reducing diagnostic error momentum.

The prevalence and impact of unprofessional behaviour among hospital workers: a survey in seven Australian hospitals

OBJECTIVE

To identify individual and organisational factors associated with the prevalence, type and impact of unprofessional behaviours among hospital employees.

DESIGN, SETTING, PARTICIPANTS

Staff in seven metropolitan tertiary hospitals operated by one health care provider in three states were surveyed (Dec 2017 - Nov 2018) about their experience of unprofessional behaviours - 21 classified as incivility or bullying and five as extreme unprofessional behaviour (eg, sexual or physical assault) - and their perceived impact on personal wellbeing, teamwork and care quality, as well as about their speaking-up skills.

MAIN OUTCOME MEASURES

Frequency of experiencing 26 unprofessional behaviours during the preceding 12 months; factors associated with experiencing unprofessional behaviour and its impact, including self-reported speaking-up skills.

RESULTS

Valid surveys (more than 60% of questions answered) were submitted by 5178 of an estimated 15 213 staff members (response rate, 34.0%). 4846 respondents (93.6%; 95% CI, 92.9-94.2%) reported experiencing at least one unprofessional behaviour during the preceding year, including 2009 (38.8%; 95% CI, 37.5-40.1%) who reported weekly or more frequent incivility or bullying; 753 (14.5%; 95% CI, 13.6-15.5%) reported extreme unprofessional behaviour. Nurses and non-clinical staff members aged 25-34 years reported incivility/bullying and extreme behaviour more often than other staff and age groups respectively. Staff with self-reported speaking-up skills experienced less incivility/bullying (odds ratio [OR], 0.53; 95% CI, 0.46-0.61) and extreme behaviour (OR, 0.80; 95% CI, 0.67-0.97), and also less frequently an impact on their personal wellbeing (OR, 0.44; 95% CI, 0.38-0.51).

CONCLUSIONS

Unprofessional behaviour is common among hospital workers. Tolerance for low level poor behaviour may be an enabler for more serious misbehaviour that endangers staff wellbeing and patient safety. Training staff about speaking up is required, together with organisational processes for effectively eliminating unprofessional behaviour.

Patient Safety Culture in EU Legislation

Patient safety means a condition in which a patient does not suffer any unnecessary actual harm, nor is exposed to any potential harm related to healthcare. The World Health Organization’s recognition of patient safety, as one of the most important factors in determining high quality healthcare, initiated the systematic introduction of changes in the approach to this issue, both globally and on the level of individual healthcare service providers. In order to enhance the quality and ensure the safety of healthcare services provided, national, European Union, and worldwide institutions focus on the introduction of a so-called patient safety culture. The creation of this safety culture would not be possible without the establishment of its legal framework. The purpose of this article is to shed light on the legislative achievements of the European Union within patient safety, taking into consideration acts that summarize the level of implementation of individual recommendations. This study can be useful both for those who focus their scientific interests on the subject of patient safety and those who need concise information on the legislative measures of the Community in this respect, as well as for medical personnel who want to become acquainted with this issue without reading comprehensive legal acts.

The Hidden Curriculum and Integrating Cure- and Care-Based Approaches to Medicine

Although current literature about the “cure versus care” issue tends to promote a patient-centered approach, the disease-centered approach remains the prevailing model in practice. The perceived dichotomy between the two approaches has created a barrier that could make it difficult for medical students and physicians to integrate psychosocial aspects of patient care into the prevailing disease-based model. This article examines the influence of the formal and hidden curricula on the perception of these two approaches and finds that the hidden curriculum perpetuates the notion that “cure” and “care” based approaches are dichotomous despite significant changes in formal curricula that promote a more integrated approach. The authors argue that it is detrimental for clinicians to view the two approaches as oppositional rather than complementary and attempt to give recommendations on how the influence of the hidden curriculum can be reduced to get a both-cure-and-care-approach, rather than an either-cure-or-care-approach.

Development of a framework to describe patient and family harm from disrespect and promote improvements in quality and safety: a scoping review

PURPOSE

Patients and families may experience 'non-physical' harm from interactions with the healthcare system, including emotional, psychological, socio-behavioral or financial harm, some of which may be related to experiences of disrespect. We sought to use the current literature to develop a practical, improvement-oriented framework to recognize, describe and help prevent such events.

DATA SOURCES

Searches were performed in PubMed, Embase, PsychINFO, CINAHL, Health Business Elite and ProQuest Dissertations & Theses: Global: Health & Medicine, from their inception through July 2017.

STUDY SELECTION

Two authors reviewed titles, abstracts, full texts, references and cited-by lists to identify articles describing approaches to understanding patient/family experiences of disrespect.

DATA EXTRACTION

Findings were evaluated using integrative review methodology.

RESULTS OF DATA SYNTHESIS

Three-thousand eight hundred and eighty two abstracts were reviewed. Twenty three articles were identified. Components of experiences of disrespect included: (1) numerous care processes; (2) a wide range of healthcare professional and organizational behaviors; (3) contributing factors, including patient- and professional-related factors, the environment of work and care, leadership, policies, processes and culture; (4) important consequences of disrespect, including behavioral changes and health impacts on patients and families, negative effects on professionals' subsequent interactions, and patient attrition from organizations and (5) factors both intrinsic and extrinsic to patients that can modify the consequences of disrespect.

CONCLUSION

A generalizable framework for understanding disrespect experienced by patients/families in healthcare may help organizations better prevent non-physical harms. Future work should prospectively test and refine the framework we described so as to facilitate its integration into organizations' existing operational systems.

Simulation-based acquisition of non-technical skills to improve patient safety

Traditional surgical training has focused on the acquisition of technical skills and knowledge with minimal focus on teaching nontechnical skills. Patient safety depends on both technical and nontechnical skills, with a higher rate of non-technical skills failure leading to patient harm. Many surgical training and regulatory bodies have incorporated nontechnical skills in the required competencies of a surgeon, but few have introduced formal training in nontechnical skills. Emerging research shows simulation-based education to be a powerful tool to teach nontechnical skills to individual surgeons and surgeons in training, and to interprofessional surgical teams with subsequent improvement of patient safety outcomes.

Systematic review protocol examining the influence of surgeon personality on perioperative decision making in abdominal surgery

INTRODUCTION

There is limited published literature exploring how the personality traits of surgeons may influence preoperative decision making, particularly in the context of visceral/abdominal surgery. Multiple validated personality scoring systems exist and have been used to describe surgeon personalities previously. The degree to which each trait is expressed by abdominal surgeons is neither currently known, nor the impact of these traits on postoperative outcomes. The protocol has been written in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.

METHODS AND ANALYSIS

The search strategy has been developed by a Health Scientist Librarian in collaboration with the review team. The search was conducted on 1st October 2019.Database subject headings and text words relating to 'abdominal/general surgeons', 'personality', 'postoperative outcomes' and 'decision making' formed the basis of our literature search strategy; the MEDLINE, EMBASE, PsycInfo and Cochrane databases will be searched. Three reviewers will independently screen and appraise articles, with a fourth reviewer utilised if disagreements arise.A systematic narrative synthesis will be performed, with information presented in text and table format. These will summarise the findings and characteristics of any included studies. Using guidance from the Centre for Reviews and Dissemination, the reviewers will describe the potential relationship and findings between studies using the narrative synthesis. Studies will only be reported if they are felt to have low or mid-levels of bias. Studies felt to display high levels of bias will be excluded.

ETHICS AND DISSEMINATION

This study does not require ethical approval. The formal systematic review will be submitted for peer reviewed publication and presented at relevant conferences. The methods may inform future reviews in other surgical specialties regarding surgeon personality.

PROSPERO REGISTRATION NUMBER

CRD42019151375.

Psychological safety, the hidden curriculum, and ambiguity in medicine

Psychological safety is a feeling that individuals are comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution. It has long been recognized as part of successful patient safety and quality improvement processes. However, in the realm of medical education, psychological safety is a relatively unknown concept to many educators and learners alike. Learners, whether students or postgraduate trainees, are in a phase of cognitive apprenticeship whereby they learn not only skills and knowledge from teachers as part of an explicit and formal curriculum. At the same time, a hidden curriculum is also part of the learning environment in the form of norms, values, and behaviors exhibited by teachers. These norms, values, and behaviors become part of the culture of the clinical learning environment. The vulnerability of learners in this environment is magnified by the hierarchal nature of medicine, and the complexity, uncertainty, and the ambiguity inherent to medical conditions. This is especially true of cognitive specialties such as rheumatology. Educators who engage in unprofessional behaviors that result in learner humiliation and shame may serve to dampen productive discourse and scientific dialog. Therefore, educators must embrace psychological safety to foster learning and facilitate high-performing teams in the clinical learning environment.Key Points• Psychological safety improves communication and teamwork by allowing individuals to be comfortable expressing and being themselves, as well as comfortable sharing concerns and mistakes without fear of embarrassment, shame, ridicule, or retribution.• Commonly studied in the context of patient safety and quality improvement, psychological safety should extend towards medical education particularly in the context of allowing medical students and postgraduate trainees to be able to voice clinical reasoning in the face of ambiguity.• Educators take on a leadership role when having learners under their supervision; as leaders, educators are the prime movers of psychological safety• Learners in the process of developing their self-identity in the context of their chosen profession adopt not only knowledge and skills within the framework of an explicit and formal curriculum but also norms and values from daily behavior and language educators present in the clinical learning environment of learners; these norms and values are collectively part of the hidden curriculum.