Incivility and the clinical learner

Incivility in healthcare: the impact of poor communication

Incivility is a common issue within healthcare in the UK and internationally. Experienced by at least one-third of staff within the UK National Health Service, incivility has been demonstrated to have significant negative implications on both patient care and healthcare staff. These include contributing to direct medical errors, diagnostic inaccuracy and team communication, with a large associated cost burden, while for staff it has significant negative impacts on retention, productivity and morale. Proposed methods do already exist to both prevent and address incivility, and it is in the interest of healthcare institutions, for their patients and staff, to investigate incivility and adopt these methods. This review explores existing literature on the effects of incivility, researched strategies to address it, as well as the proposed ways of integrating these. Through raising awareness and exploring these issues, our aim is to increase recognition of incivility, as well as inspire healthcare managers and leaders to collectively take efforts to reduce the rates of incivility.

Nursing students' experiences of unprofessional behaviours and associations with guideline compliance: A multicenter survey

AIMS

To assess the reported prevalence of unprofessional behaviours, including incivility and bullying, experienced by nursing students during their clinical practice. To assess the prevalence of students' abilities to speak up about unprofessional behaviours encountered and infection control concerns; their compliance with standard precautions and COVID-19 guidelines; and their perceived responsibility for infection prevention. Lastly, to describe the potential impact of unprofessional behaviour on compliance with these guidelines.

BACKGROUND

Unprofessional behaviours in healthcare settings are associated with a wide range of individual and organisational negative outcomes for nurses and nursing students, which may affect patient safety. The COVID-19 pandemic created new challenges for clinical education and for infection control.

DESIGN

A descriptive cross-sectional design.

METHODS

A multi-centre survey was carried out in six academic universities and colleges in Israel. The research study involved 369 undergraduate nursing students during 2022. Their clinical experiences were assessed using an online questionnaire. The STROBE guideline was used for accurate reporting.

RESULTS

301 (81.6%) students reported experience of unprofessional behaviour while undertaking clinical practice. Students with reported skills to speak up about unprofessional behaviour were less likely to report having experienced these behaviours (p = 0.003). Students who did not experience unprofessional behaviours were more likely to report higher compliance with standard and COVID-19 precaution guidelines (OR 3.624, 95% CI 1.790-7.335, p < 0.001). These students also had a higher perception of personal responsibility toward patient safety (OR 1.757, 95% CI 1.215-2.541, p = 0.003).

CONCLUSIONS

Nursing students experiencing unprofessional behaviours in the clinical setting reported lower compliance with standard and COVID-19 precautions. In addition, cultivating personal responsibility towards patients' safety may have a positive impact on guidelines compliance. Nursing educators and leaders should develop strategies to enable students to better cope with unprofessional behaviours. Closer cooperation between all stakeholders may promote civility among nurses and nursing students in the clinical setting.

Incivility in medical education: a scoping review

Incivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. In this scoping review, we use the term incivility to encompass a spectrum of behaviors that occur across the continuum of medical education, and which include verbal abuse including rude or dismissive conduct, sexual and racial harassment and discrimination, and sexual and physical assault. We identified research on incivility involving medical students, residents and fellows, and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. Our results reinforce that incivility is likely under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients, not emphasized in previous reviews. The authors suggest a zero-tolerance national policy if this problem is to be resolved.

Senior surgeons as role models in the operating theatre: a thematic analysis through the lens of aristotelian ethics

BACKGROUND

Surgeons are commonly evaluated by surgical skills and outcomes rather than their character traits. We sought to examine role model behaviours of senior surgeons through the lens of Aristotelian (virtue) ethics.

METHODS

Semi-structured focus group interviews were undertaken of anaesthetic trainees at a large university hospital NHS Foundation Trust and transcripts were subjected to thematic analysis to yield themes and subthemes. Participation of the trainees was entirely voluntary and focus groups were conducted using Zoom™.

RESULTS

The overarching themes identified were 'Teamwork makes the dream work', 'Captain of the ship' and 'Strong foundations'.

CONCLUSION

We hope to take lessons learnt in conjunction with our previous work to help refocus surgical training towards a process of character reformation, rather than simply imparting technical skills to trainees.

Wearing hats and blending boundaries: harmonising professional identities for clinician simulation educators

Many clinicians working in healthcare simulation struggle with competing dual identities of clinician and educator, whilst those who harmonise these identities are observed to be highly effective teachers and clinicians. Professional identity formation (PIF) theories offer a conceptual framework for considering this dilemma. However, many clinician simulation educators lack practical guidance for translating these theories and are unable to develop or align their dual identities.

An unusual experience involving the first author’s suspension of disbelief as a simulation facilitator sparked a novel reflection on his dual identity as a clinician and as a simulation educator. He re-framed his clinician and simulation ‘hats’ as cooperative and fluid rather than competing and compartmentalised. He recognised that these dual identities could flow between clinical and simulation environments through leaky ‘blended boundaries’ rather than being restricted by environmental demarcations.

This personal story is shared and reflected upon to offer a practical ‘hats and boundaries’ model. Experimenting with the model in both clinical and simulation workplaces presents opportunities for PIF and alignment of dual identities. The model may help other clinician simulation educators navigate the complexities of merging their dual identities.

It's not about the errors, it's about the learning: How the Royal College of Radiologists has developed a Radiology Events and Learning process in the United Kingdom

The Royal College of Radiologists (RCR) is based in the United Kingdom but is a global organisation with members and fellows worldwide. In this invited article, the chair of the RCR Radiology Events and Learning (REAL) panel recounts his experience in looking at radiological errors. He starts with his personal work auditing his own mistakes as a junior consultant, describes what he learned in his departmental role in a large teaching hospital running a Radiology Events and Learning Meeting (REALM) and gives an overview of some of the work done over the last two decades by the RCR. This includes publishing national guidelines which set standards for running a REALM, setting up the REAL panel which produces a quarterly newsletter of cases from RCR members, and running an annual conference to share information with local radiology departments around the country. A review of the literature describing the drivers for this work and looking at the parallels with industry lies alongside the practical tips he found useful which he hopes would be helpful to anyone setting up their own departmental errors or discrepancy meeting.

Prevalence of incivility between ophthalmology and emergency medicine residents during interdepartmental consultations

OBJECTIVES

Since incivility is linked to adverse effects in patient care and health care worker well-being, evaluation of the prevalence of incivility during the formative years of residency training is warranted. The aim of this study was to determine the perceived presence and degree of incivility between emergency medicine (EM) and ophthalmology residents during emergency department (ED) consultations.

METHODS

We conducted a single-site, survey-based study, targeted to ophthalmology and EM residents. The survey we distributed included questions adapted from validated and widely used surveys measuring incivility in the workplace (Workplace Incivility Scale) and incivility within the ED.

RESULTS

Ophthalmology (13/15, 86.7%) and EM (42/48, 87.5%) residents participated, with an overall response rate of 55 of 63 (87.3%). Most residents (47/55, 85.5%) reported some degree of incivility during consultations, with a greater proportion of females reporting incivility (100%) than males (77.4%, p = 0.033). A total of 52.7% of respondents reported occurrence of incivility on a quarterly basis; 21.8% reported monthly, 10.9% weekly, and none daily. Incivilities were reported most commonly during nonurgent consults (85.5%). The two most common incivilities reported by trainees were when the other party paid little attention to their statements or opinions (80% of residents) or doubted their professional judgment (74.5% of residents). More female trainees reported jokes being told at their expense compared to males (15.8% vs. 0%, p = 0.049). Residents most often attributed incivility to stress (78.2%), loss of empathy/burnout (63.6%), or attempts to shift responsibility to another party (60.0%). Among EM residents surveyed, incivility was identified as occurring most often during consultations with surgical specialties.

CONCLUSIONS

Incivility during interdepartmental consultations between EM and ophthalmology is commonly reported by physicians-in-training. It occurs more often during consultations deemed as nonurgent and is more commonly reported by females. Given its associations with adverse outcomes, interventions to decrease incivility early in training may be warranted.

Pilot study to evaluate safety culture perception in the operating theatres of an acute NHS Trust using the National Air Traffic Services (NATS) App

An area critical to safety in an organisation is the perceived and actual culture. National Air Traffic Services (NATS) work closely with large safety-critical industries including various aviation companies to enable them to identify strengths and vulnerabilities with the aim of improving safe practice. NATS have developed a simple free downloadable self-assessment App that individuals can use to assess their own culture perception in their organisation. The App has 16 questions arranged in four domains but to our knowledge it has not been used to date in healthcare. As part of the initiatives to improve staff culture, we evaluated operating theatre colleagues' safety perception in our large acute NHS Trust in a pilot study using the NATS safety App. Staff downloaded the App to their smart device before completing it. Responses were sent anonymously through the App and collated by NATS. A total of 146 colleagues downloaded and completed the questionnaire. One hundred and seventeen staff (80%) felt encouraged to report safety concerns, but 86% (n=126) confirmed a lack of available support from healthcare managers. Only 43% of respondents (n=63) would find it easy to challenge colleagues if they observed unsafe behaviour. This pilot study has identified positive indicators of an evolving NHS safety culture, and some concerns about speaking up, support, and challenging colleagues without fear. These issues are known to occur across healthcare. Further work is needed in the NHS to provide a supportive environment to improve patient safety, and lower hierarchy in surgical teams.