Clinician responses to disruptive intraoperative behaviour: patterns and norms identified from a multinational survey.

PURPOSE: Disruptive intraoperative behaviour can have detrimental consequences for clinicians, institutions, and patients. The way victims and witnesses respond to disruptive behaviour can ameliorate or exacerbate consequences. Nevertheless, previous research has neither described the responses of a multinational sample of clinicians nor developed tools to recognize and evaluate responses. METHODS: After obtaining ethics committee approval, 23 perioperative organizations distributed a survey evaluating clinician responses to disruptive behaviour. We grouped responses into four response strategies: passive, assertive, manipulative, and malicious. Thereafter, we derived norms (i.e., percentile distributions) for each response strategy using empirical distribution functions. Latent profile analysis identified groups of clinicians balancing their use of the four response strategies differently (i.e., response pattern groups). We used Chi square tests to examine associations between response pattern groups and respondent demographics. RESULTS: We analyzed 4,789 complete responses. In response to disruptive behaviour, 33.7% of clinicians altered medical care in ways that were unindicated, 54.6% avoided communication with team members, and 12.1% misled the offender. Profile analysis identified five response pattern groups: extreme passive-predominant (30.5% of clinicians), extreme assertive-predominant (20.5%), moderate passive-predominant (18.9%), moderate assertive-predominant (26.5%), and a disparate pattern (greater use of manipulative and malicious responses) (3.5%). Profession, sex, management responsibilities, and sexual orientation predicted the response pattern group (all, P < 0.001). DISCUSSION: The responses of thousands of clinicians involved passivity, manipulativeness, or maliciousness. We present norms and a response pattern classification to help organizations evaluate responses, recognize response patterns, and provide tailored support to victims and witnesses.

RéSUMé: OBJECTIF: Les comportements peropératoires perturbateurs ont des effets délétères tant sur l'équipe clinique que sur les institutions et la patientèle. La façon dont les victimes et les témoins réagissent à un comportement perturbateur peut en atténuer ou exacerber les conséquences. Néanmoins, les recherches antérieures n'ont pas décrit les réponses d'un échantillon multinational de clinicien·nes ni développé d'outils pour reconnaître et évaluer les réponses. MéTHODE: Après l'obtention de l'approbation du comité d'éthique, 23 organisations de soins périopératoires ont distribué un sondage évaluant les réponses des cliniciennes et cliniciens aux comportements perturbateurs. Nous avons regroupé les réponses en quatre stratégies de réponse : passive, assertive, manipulatrice et malveillante. Par la suite, nous avons dérivé des normes (c'est-à-dire des distributions centiles) pour chaque stratégie de réponse à l'aide de fonctions de distribution empiriques. L'analyse des profils latents a permis d'identifier des groupes de clinicien·nes équilibrant différemment leur utilisation des quatre stratégies de réponse (c.-à-d. des groupes de modèles de réponse). Nous avons utilisé des tests du chi carré pour examiner les associations entre les groupes de modèles de réponse et les données démographiques des répondant·es. RéSULTATS: Nous avons analysé 4789 réponses complètes. En réponse à un comportement perturbateur, 33,7 % des clinicien·nes ont modifié les soins médicaux d'une manière qui n'était pas indiquée, 54,6 % ont évité de communiquer avec les membres de l'équipe et 12,1 % ont induit la personne délinquante en erreur. L'analyse du profil a permis d'identifier cinq groupes de modèles de réponse : passif extrême-prédominant (30,5 % des clinicien·nes), affirmation de soi extrême-prédominante (20,5 %), passif modéré-prédominant (18,9 %), affirmation de soi modérée-prédominante (26,5 %) et attitudes disparates (utilisation accrue de réponses manipulatrices et malveillantes) (3,5 %). La profession, le sexe, les responsabilités de gestion et l'orientation sexuelle prédisaient le groupe de type de réponse (tous, P < 0,001). DISCUSSION: Les réponses de milliers de clinicien·nes impliquaient la passivité, la manipulation ou la malveillance. Nous présentons des normes et une classification des modèles d'intervention pour aider les organisations à évaluer les réponses, à reconnaître les modèles d'intervention et à fournir un soutien personnalisé aux victimes et aux témoins.

Restricted versus liberal intraoperative benzodiazepine use in cardiac anaesthesia for reducing delirium (B-Free Pilot): a pilot, multicentre, randomised, cluster crossover trial.

BACKGROUND: Delirium is common after cardiac surgery and is associated with adverse outcomes. Perioperative benzodiazepine use is associated with delirium and is common during cardiac surgery, which may increase the risk of postoperative delirium. We undertook a pilot study to inform the feasibility of a large randomised cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared with liberal administration) would reduce delirium. METHODS: We conducted a two-centre, pilot, randomised cluster crossover trial with four 4 week crossover periods. Each centre was randomised to a policy of restricted or liberal use, and then alternated between the two policies during the remaining three periods. Our feasibility outcomes were adherence to each policy (goal ≥80%) and outcome assessment (one delirium assessment per day in the ICU in ≥90% of participants). We also evaluated the incidence of intraoperative awareness in one site using serial Brice questionnaires. RESULTS: Of 800 patients undergoing cardiac surgery during the trial period, 127/800 (15.9%) had delirium. Of these, 355/389 (91.3%) received benzodiazepines during the liberal benzodiazepine periods and 363/411 (88.3%) did not receive benzodiazepines during the restricted benzodiazepine periods. Amongst the 800 patients, 740 (92.5%) had ≥1 postoperative delirium assessment per day in the ICU. Of 521 patients screened for intraoperative awareness, one patient (0.2%), managed during the restricted benzodiazepine period (but who received benzodiazepine), experienced intraoperative awareness. CONCLUSIONS: This pilot study demonstrates the feasibility of a large, multicentre, randomised, cluster crossover trial examining whether an institutional policy of restricted vs liberal benzodiazepine use during cardiac surgery will reduce postoperative delirium. CLINICAL TRIAL REGISTRATION: NCT03053869.

Disruptive behaviour in the operating room is under-reported: an international survey.

PURPOSE: The purpose of this study was to investigate the reporting habits of clinicians who have been exposed to disruptive behaviour in the operating room (OR) and assess their satisfaction with management's responses to this issue. METHODS: Ethics committee approval was obtained. This was a pre-specified sub-study of a larger survey examining disruptive behaviour, which was distributed to OR clinicians in seven countries. Using Likert-style questions, this study ascertained the proportion of disruptive intraoperative behaviour that clinicians reported to management, as well as their degree of satisfaction with management's responses. Binomial logistic regression identified socio-demographic, exposure-related, and behavioural predictors that a clinician would never report disruptive behaviour. RESULTS: Four thousand, seven hundred and seventy-five respondents were part of the sub-study. Disruptive behaviour was under-reported by 96.5% (95% confidence interval [CI], 95.9 to 97.0) of respondents, and never reported by 30.9% (95% CI, 29.6 to 32.2) of respondents. Only 21.0% (95% CI, 19.8 to 22.2) of respondents expressed satisfaction with management's responses. Numerous socio-demographic, exposure-related, and behavioural predictors of reporting habits were identified. Socio-demographic groups who had higher odds of never reporting disruptive behaviour included younger clinicians, clinicians without management responsibilities, both anesthesiologists and surgeons (compared with nurses), biological females, and heterosexuals (all P < 0.05). CONCLUSIONS: Disruptive behaviour was under-reported by nearly all clinicians surveyed, and only one in five were satisfied with management's responses. For healthcare systems to meaningfully address the issue of disruptive behaviour, management must create reporting systems that clinicians will use. They must also respond in ways that clinicians can rely on to affect necessary change.

Abusive behaviour in Canadian and US operating rooms.

BACKGROUND: Disruptive intraoperative behaviour has detrimental effects on clinicians, institutions, and patients. Abusive behaviour is an egregious form of disruptive behaviour that has a particular risk of detrimental consequences. The prevalence of abusive behaviour in the operating room (OR) is uncertain. We therefore examined the prevalence and frequency of exposure to abusive behaviour in a cohort of Canadian and US OR clinicians. METHODS: This was a sub-study of an international survey examining disruptive behaviour in the OR. It included a cohort of clinicians from Canada and the United States who were recruited from six perioperative associations and two institutions. Clinicians were asked about their intraoperative exposure to three abusive behaviours: physical assault, verbal threats, and intimidating invasion of their personal space. From the responses, we derived the proportion of clinicians who experienced or witnessed abuse (i.e., prevalence) and the number of abusive events experienced by all respondents (i.e., frequency). RESULTS: Of the 7,465 clinicians who responded to the original international survey, 2,875 were part of this abuse sub-study (United States =1,010, Canada = 1,865). In the preceding year, 667 clinicians (23.2%; 95% confidence interval [CI], 21.6 to 24.8) personally experienced abuse, while 1,121 clinicians (39.0%; 95% CI, 37.2 to 40.8) witnessed colleagues being abused. In total, the group of respondents reported experiencing 14,237 abusive events in the preceding year. CONCLUSIONS: Both the number of clinicians who are exposed to abusive behaviour and the large number of reported events are concerning. Since these events can undermine team-work and affect patients, coworkers, and institutions, efforts are needed to further evaluate and manage the problem.

RéSUMé: CONTEXTE: Les comportements peropératoires perturbateurs ont des effets délétères tant sur les cliniciens que sur les institutions et les patients. Un comportement dit abusif est une forme flagrante de comportement perturbateur qui comporte un risque particulier de conséquences délétères. La prévalence des comportements abusifs en salle d'opération (SOP) est inconnue. Nous avons donc examiné la prévalence et la fréquence d'exposition à des comportements abusifs d'une cohorte de cliniciens de SOP canadiens et américains. MéTHODE: Il s'agit d'une sous-étude d'un sondage international examinant les comportements perturbateurs en SOP. Notre étude a inclus une cohorte de cliniciens du Canada et des États-Unis recrutés dans six associations périopératoires et deux institutions. On a interrogé les cliniciens à propos de leur exposition peropératoire à trois comportements abusifs : les agressions physiques, les menaces verbales et l'invasion intimidante de leur espace personnel. À partir de leurs réponses, nous avons dérivé la proportion de cliniciens ayant été victimes ou témoins d'abus (soit la prévalence) et le nombre d'événements abusifs subis par tous les répondants (soit la fréquence). RéSULTATS: Parmi les 7465 cliniciens ayant répondu au sondage international original, 2875 ont pris part à cette sous-étude sur les abus (États-Unis =1010, Canada = 1865). Au cours de l'année précédant le sondage, 667 cliniciens (23,2 %; intervalle de confiance [IC] 95 %, 21,6 à 24,8) ont personnellement subi des abus, alors que 1121 cliniciens (39,0 %; IC 95 %, 37,2 à 40,8) ont été témoins d'abus à l'égard de collègues. Au total, le groupe de répondants a été exposé à 14 237 événements abusifs au cours de l'année précédente. CONCLUSION: Tant le nombre de cliniciens exposés à des comportements abusifs que le nombre important d'événements rapportés sont inquiétants. Étant donné que ces événements peuvent nuire au travail d'équipe et affecter les patients, les collègues et les institutions, des efforts sont nécessaires afin d'évaluer ce problème et de le régler.

Disruptive behavior in the operating room: prevalence, consequences, prevention, and management.

PURPOSE OF REVIEW: Disruptive workplace behavior can have serious consequences to clinicians, institutions, and patients. There is a range of disruptive behaviors, and the consequences are often underappreciated. The purpose of this manuscript is to review the definition, prevalence, consequences, prevention, and management of disruptive behavior in the operating room. RECENT FINDINGS: Although a small minority of operating room clinicians act disruptively, 98% of clinicians report having recently been exposed to disruptive behavior, with the average being 64 events per clinician per year. The causes include intrapersonal factors, workplace relationships, workplace logistics, and broader contextual factors. Disruptive behavior undermines patient care by decreasing individual and team clinical performance. It decreases clinician well being, sets a poor example for medical students who are susceptible to negative role models, and decreases hospital efficiency. The way that clinicians respond to disruptive behavior may either exacerbate or reduce the consequences of the behavior. In order to prevent disruptive behavior, the causes must be addressed. Institutions must have robust policies to deal with disruptive behavior and have preventive measures that include regular staff education. Whenever disruptive behavior does occur, it must be expeditiously addressed, which may include graded discipline. SUMMARY: Disruptive intraoperative behavior is prevalent and harms multiple parties in the operating room. Institutions require comprehensive measures to prevent the behavior and to mitigate consequences.