Incivility in orthopaedic surgery: Unmasking the hidden epidemic

Deiary Kader and Paul Banaszkiewicz

Deiary Kader is a consultant specialising in knee arthroplasty and sports injury surgery at the South West London Elective Orthopaedic Centre (SWLEOC), where he serves as the Director of Research. Professor Kader is committed to the clinical integration of AI in orthopaedics. He is the founder of NGMV Medical Volunteers & Life Academy, was a war reconstruction surgeon for the ICRC in Lebanon, and is currently serving as a surgeon for Swisscross in Iraq.

Paul Banaszkiewicz is a Consultant trauma and orthopaedic surgeon working at the Queen Elizabeth Hospital Gateshead. He is a fellow of the Higher Education Academy, fellow of the Academy of Medical Educators and has a Master’s degree in Medical Education from Newcastle University. He is a Visiting Professor at Northumbria University, a BOA Council Trustee, JTO Editor and the current BOA Education and Careers Chair.

In the fast-paced, high-pressure environment of healthcare, particularly within orthopaedic surgery, incivility is an under-acknowledged yet pervasive issue that can significantly corrode the pillars of healthcare.

Unprofessional and disruptive behaviour in the surgical environment can take many forms. Surgeons and managers may display such conduct towards one another, their juniors, and other staff members, creating a toxic work atmosphere. These behaviours can range from overt acts of rudeness and intimidation to subtler forms of disrespect and undermining, manifesting in dismissive exchanges, non-constructive criticism, passing blame for mistakes, withholding information, and passive-aggressive behaviours. Such actions not only create a hostile work environment but also fuel stress, stifle collaboration, and disrupt the fabric of cohesive team dynamics. Moreover, they adversely affect staff retention, productivity, and morale.

Reports of unprofessional behaviour vary among staff, with black and minority ethnic employees experiencing this more often. In addition, evidence indicates women are more commonly targeted than men [1,2].

But why does this happen, and what are the consequences of such behaviours? This article explores the impacts, causes and remedies for incivility, specifically addressing orthopaedic surgeons and the broader healthcare community.

The impact of incivility

The cost of incivility extends beyond hurt feelings, it has tangible consequences:

• Reduced team efficiency: Incivility disrupts the workflow and can lead to poor patient outcomes. Indeed, a single rude remark was found to reduce the effectiveness of doctors and nurses by over 50% during a simulated critical scenario [3].

• Medical errors go unchallenged: Stress and distraction from uncivil behaviour can lead to mistakes. In a 2003 survey conducted by the Institute for Safe Medication Practices (ISMP) on workplace intimidation, 40% of those surveyed acknowledged that they refrained from querying orders they were uncertain about, preferring to presume they were accurate, rather than confront a prescriber whom they viewed as intimidating [4].

• Diminished morale and turnover: Continuous exposure to a toxic work environment leads to higher staff turnover rates.

• Patient satisfaction: An uncivil environment can spill over into patient care, affecting their experience and trust in the healthcare system.

• Higher complication rate: A detailed US study involving 200 surgeons and 13,653 patients found that patients treated by surgeons with higher reports of unprofessional behaviour faced a notably higher risk of surgical and medical complications5. Consider the consequences when a surgeon encounters unprofessional behaviour from a colleague just before surgery. Such distractions elevate the likelihood of surgical mistakes and complications, compromising patient safety.

Figure 1: Incivility. The red bird is being mocked and made fun of by the three other birds.

Furthermore, they can heighten the risk of injury to the surgical team and severely damage team cohesion and the overall work environment.

• Cost to the NHS: A cautious estimate suggests that the cost of unprofessional behaviour to the UK’s NHS amounted to approximately £2.28 billion per year when considering factors such as sickness absence, employee turnover, reduced productivity, compensation and litigation costs6

Figure 2: Incivility in the surgical setting.

Why, then, do surgeons, renowned for their precision and skill, fall prey to uncivil behaviour?

With a demanding unwritten code of conduct that emphasises relentless commitment and emotional stoicism, it is no surprise that the pressures of the job can manifest in uncivil behaviour.

Professionals in healthcare, particularly surgeons, operate within an unspoken ethos that prioritises patient care above all. This ethos includes:

• Dedication to long hours: Coming in early, staying late, and working nights and weekends is commonplace.

• High volume of procedures: The expectation to perform a large number of procedures often with complex demands.

• Multitasking under tight deadlines: Meeting simultaneous deadlines for different tasks and patients.

• Emotional restraint: Keeping personal issues and emotions from affecting professional responsibilities.

Such relentless standards, while aiming to uphold the highest quality of patient care, can inadvertently foster an environment where stress is high and the bandwidth for civility is low. For many, the job becomes not just a profession but an identity, and with identity so closely tied to performance, the stakes of every interaction are raised.

The psychology behind surgeon incivility

Several psychological and systemic factors contribute to this conundrum:

• Stress and burnout: The constant high-pressure environment can lead to emotional exhaustion, reducing an individual’s ability to engage positively with colleagues.

• Dehumanisation: With a focus on technical excellence, surgeons may start viewing patients — and by extension, colleagues — as tasks rather than humans, leading to depersonalisation.

• Lack of resources: Staff shortages and resource constraints increase the pressure on individuals, which can result in frustration and a higher propensity for incivility.

• Fear of error: The knowledge that a single mistake can have dire consequences may create a defensive workplace atmosphere.

• Competitive culture: The drive to be the best can sometimes overshadow the collaborative nature of healthcare, leading to aggression and disrespect.

• Challenges in expressing emotions - rethinking British stoicism: The British cultural norm of the ‘stiff upper lip’ may contribute to suppressing emotions and inhibiting open communication. Recognising that emotions are not weaknesses but natural responses that can guide more mindful interactions is crucial for fostering transparency. Emotions act as a complementary immune system, not only safeguarding our mental wellbeing but also assisting in interpreting and comprehending our environment. They facilitate our processing of and responses to social and emotional signals, leading to clearer communication and a deeper level of understanding. When we fail to express these emotions, it can result in a build-up of stress and anxiety, compromising our physical health and straining interpersonal relationships. Expressing emotions, therefore, is crucial for maintaining both our psychological balance and the quality of our connections with others.

How rudeness reduces mental bandwidth

The concept of cognitive bandwidth, demonstrated by Miller’s Law, offers insight into the profound impact incivility can have. Cognitive bandwidth, akin to a mental window, represents an individual’s capacity to concurrently process multiple thoughts or tasks. This bandwidth essentially sets the pace at which we can consciously absorb and respond to information. Miller’s Law, suggesting that the average person can hold about seven items (plus or minus two) in their working memory, highlights the finite nature of our cognitive resources.

Incivility disrupts this cognitive balance, encroaching on our mental bandwidth. When faced with negative interactions, a significant portion of our cognitive capacity is diverted towards managing these stressors, leaving less available for critical thinking and decisionmaking. This is particularly pertinent in high-stakes environments like hospitals, where staff members’ varying capacities to withstand negativity can markedly influence their mental well-being and job performance. The repercussions of diminished cognitive bandwidth in such settings are significant, with hospital staff who are preoccupied with uncivil interactions more prone to errors, memory lapses, and a lack of innovative problem solving.

Addressing the root causes

To tackle incivility, it is essential to understand and address its root causes:

• Mentorship and advocacy: The link between surgical skills and stress levels is undeniable. Evolving surgeons often face higher stress, impacting their performance. A targeted solution is a well-structured mentorship programme that offers direct access to experienced surgeons’ insights and reassurance. However, the effectiveness of such a programme largely depends on the developing surgeon’s emotional intelligence, including their willingness to seek support and accept guidance. With the right mind-set, a mentorship programme can significantly alleviate stress and enhance the skills and confidence of the doctor, leading to a more proficient and composed surgical team. Additionally, within this mentorship framework, the advocacy role of experienced surgeons becomes crucial as it ensures that developing surgeons receive personalised support, guidance, and opportunities essential for their professional growth and success.

• Leadership development: Healthcare workers often perceive courteous surgeons as leaders, regarding them as competent individuals. This perception highlights the importance of cultivating leadership skills among surgeons, emphasising emotional intelligence and strategies to navigate the pressures of the profession with grace and civility.

• Promoting reciprocity: Simple acts of kindness and civility can set off a chain reaction: as team members receive support from their peers, they are motivated to extend it to others. The impact of reciprocity on workplace dynamics cannot be overstated, resulting in a more harmonious work environment.

• Adequate staffing and resources: Ensuring that the healthcare system is adequately staffed and resourced can reduce the pressure that contributes to uncivil behaviour.

• Encouraging open dialogue: Creating safe channels for feedback and discussion can help alleviate misunderstandings and tension.

• Creating a culture of support: Fostering an environment where asking for help is normalised can decrease the perceived need for stoicism.

• Mindfulness and reflection: Taking the time to reflect on one’s behaviour and its impact can lead to greater self-awareness and civility.

• Resilience and emotional intelligence training: Equipping surgeons with tools to manage stress and engage empathetically can mitigate the rise of uncivil actions.

• Civility Quotient (CQ) Awards: Create an award programme that recognises individuals or teams with the highest ‘Civility Quotient’ based on feedback from peers, supervisors, and patients. Positive reinforcement of civil behaviour can shift the culture.

Radical candour: A pathway to change

It is imperative to clarify that advocating for civility doesn’t equate to diminishing professional rigour or fostering a laissezfaire environment. Rather, the essence lies in balancing stringent work standards with a culture of respect and motivation. This equilibrium is appropriately captured in the radical candour framework, which promotes a balanced blend of genuine empathy and straightforward feedback, advocating for leaders to deeply care while maintaining openness with their team. It is structured around two pivotal elements: demonstrating real concern for individuals beyond their professional capacities, and delivering candid, unambiguous feedback, even when it involves challenging discussions. This underscores the importance of combining sincere care with directness, avoiding counterproductive attitudes such as obnoxious aggression (critique devoid of empathy), ruinous empathy (excessive empathy that avoids crucial feedback, potentially harming individual or team performance due to unclear guidance and unaddressed errors), and manipulative insincerity (ineffective and disingenuous feedback). By adhering to this model, leaders are encouraged to foster a supportive yet honest environment, ensuring that feedback is delivered with both kindness and clarity [7].

Figure 3: Radical candour - Combining sincere care with directness to uphold stringent work standards.

Leaders, by genuinely caring for their team members, not only as professionals but as individuals, promote a foundation of trust and loyalty. Concurrently, direct and respectful challenges serve as impetuses for improvement and growth, ensuring that complacency finds no foothold. This method, centred on compassionate leadership coupled with clear expectations, not only mitigates workplace incivility but also enhances the overall team vitality, nurturing a workspace where respect, transparency, and highperformance merge, thereby optimising the collective output.

This article aims to draw the attention of regulatory authorities and healthcare governing bodies to the critical issue of unprofessional conduct and disruptive behaviours exhibited by a minority of doctors. It highlights the importance of addressing unprofessional behaviours promptly and effectively to avert dysfunction in workplaces and mitigate risks to patient safety. By tackling these issues head-on, we can ensure that healthcare institutions remain places of healing and trust, where the focus is on patient care and the well-being of both staff and patients is prioritised.

Conclusion

While the culture of healthcare, particularly in orthopaedic surgery, has historically valued stoicism and relentless dedication, it’s time to acknowledge that these values can coexist with, and indeed be enhanced by, a commitment to civility. The costs of incivility are too great to ignore, from the wellbeing of healthcare professionals to the safety of patients. By understanding the underlying causes of incivility, embracing radical candour (respectful confrontation), and fostering an environment of support and reciprocity, orthopaedic surgeons can lead the way in creating a more respectful, effective, and caring healthcare system.

References

1. NHS Staff Survey (NSS). NHS Staff Survey 2022 National results briefing. 2023 [cited 2024 Mar 10]; Available at: www. nhsstaffsurveys.com/results/national-results

2. Keller S, Yule S, Zagarese V, Parker SH. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ Open. 2020;10(6):e035471.

3. Riskin A, Erez A, Foulk TA, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015;136(3):487-95.

4. Institute for Safe Medication Practices (ISMP). Intimidation: Practitioners Speak Up About This Unresolved Problem (Part I). ISMP Medication Safety Alert! Acute Care 2004;9(5):1-3.

5. Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg. 2019;154(9):828-34.

6. Kline R, Lewis D. The price of fear: Estimating the financial cost of bullying and harassment to the NHS in England. Public Money & Management 2018:39(3);166-74.

7. Scott K. Radical Candor: How to Get What You Want by Saying What You Mean. Pan Macmillan; 2017.