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Exposure to incivility hinders clinical performance in a simulated operative crisis
  1. Daniel Katz1,
  2. Kimberly Blasius2,
  3. Robert Isaak2,
  4. Jonathan Lipps3,
  5. Michael Kushelev3,
  6. Andrew Goldberg1,
  7. Jarrett Fastman1,
  8. Benjamin Marsh1,
  9. Samuel DeMaria1
  1. 1 Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
  2. 2 Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3 Anesthesiology, Ohio State University, Columbus, Ohio, USA
  1. Correspondence to Dr Daniel Katz, Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai Department of Anesthesiology Perioperative and Pain Medicine, New York city, NY 10029, USA; daniel.katz{at}


Background Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. We therefore sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.

Methods This is a multicentre, prospective, randomised control trial from three academic centres. Anaesthesiology residents were randomly assigned to either a normal or ‘rude’ environment and subjected to a validated simulated operating room crisis. Technical and non-technical performance domains including vigilance, diagnosis, communication and patient management were graded on survey with Likert scales by blinded raters and compared between groups.

Results 76 participants underwent randomisation with 67 encounters included for analysis (34 control, 33 intervention). Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). Binary logistic regression to predict this outcome was performed to assess impact of confounders. Only the presence of incivility reached statistical significance (OR 0.110, 95% CI 0.022 to 0.544, p=0.007). 65% of the rude group believed the surgical environment negatively impacted performance; however, self-reported performance assessment on a Likert scale was similar between groups (p=0.112).

Conclusion Although self-assessment scores were similar, incivility had a negative impact on performance. Multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects. It is imperative that these behaviours be eliminated from operating room culture and that interpersonal communication in high-stress environments be incorporated into medical training.

  • anaesthesia
  • crisis management
  • medical education
  • patient safety
  • simulation

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  • Contributors All of the authors listed on this manuscript have met the requirements for authorship as set forth by the journal.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Ethics approval Icahn School of Medicine PPHS Office (IRB) We were given an IRB exemption for our study #16-00623.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No data are available.