The Impact of Rudeness on Medical Team Performance: A Randomized Trial

Riskin. Pediatrics 2015:136(3), doi: 10.1542/peds.2015-1385

Clinical Question

• Does a neonatal intensive care team who is affected by rudeness compared to no rudeness impair team members’ diagnostic and procedural performance?

Background

• Iatrogenic events occur in ~4% of hospital admissions with half of these being preventable and 14% resulting in death. These rates are higher in patients that are critically ill
• Studies have suggested that the risk of iatrogenic events is increased by practitioner stressors. One such stressor may be rudeness

Design

• Randomised controlled trial
  • Stratified by unit and hospital
  • Randomisation performed by research assistant
  • ‘Randomly assigned to teams at the same time and shift of the day based on availability in the NICU’
  • Randomly assigned to the control or incivility group
• Experimenter and the participants were blinded to the group allocation
• Participants performed a 1-hour simulation in their own NICU followed by a workshop on team reflexivity
  • Simulation observed on webcam by ‘international world expert’
  • Managed pre-term infant with necrotizing enterocolitis who was in respiratory failure and shock, who then went on to develop a cardiac tamponade secondary to a central line
• Assessor of performance blinded to group assignment (2 senior physicians and 1 senior nurse read written documentation and watched recorded simulation)
  • Performance rated on 5 point scale (1 = failed, 2 = poor, 3 = moderate, 4 = good, 5 = excellent) with descriptions and examples of indicative behaviour for each score. Diagnostic and procedural performance were assessed
• Sample size calculation of 10-11 teams per condition – the power of the study was not stated

Setting

• 4 Israeli Neonatal Intensive Care Units

Population

• Inclusion:
  • Neonatal team
    • Comprising of 1 physician and 2 nurses from the same unit
    • Mean occupational tenure of 10.6 +-8.6 years
    • Exclusion criteria: none stated
• 24 teams of 3 randomised

Comparing intervention and control groups no significant difference in age, sex, hierarchal status, level of expertise, tenure of participants

Intervention

• Subjected to rude behaviour
  • Participants shown pre-recorded videos that they were told were live
    • Prior to starting simulation
      • Expert stated that he had “already observed a number of groups from other hospitals and he was not impressed by the quality of medicine in Israel”
    • Half way through simulation (at 10 minutes)
      • Expert stated “medical staff like those observed in Israel wouldn’t last a week in his unit” and that he “hoped they would learn and improve from the workshop but he hoped he would not get sick in Israel”
  • Participants rated the behaviour as rude with a mean score of 3.24/4

Control

• Not subjected to rude behaviour
  • Participants were shown similar videos as intervention groups but without the rude comments
  • Participants rated the behaviour as rude with a mean score of 1.21/4

Outcome

• Diagnostic performance – significantly lower in team exposed to rudeness
  • 2.65 vs. 3.18, p=0.005
• Procedural performance – significantly lower in team exposed to rudeness
  • 2.77 vs. 3.26, p=0.008
• Multivariate analysis demonstrated that~12% of the variance in medical performance was explained by rudeness
• Standardised coefficients for mediation model
  • Rudeness was significantly associated with reduced
    • Information sharing
      • -0.51, 95% C.I. -0.87 to -0.15, p<0.01
    • Help-seeking
      • -0.38, 95% C.I. -0.7 to -0.08, p<0.05
  • Information sharing had a significant positive relationship with diagnostic performance (0.47, p<0.01) but not with procedural performance
  • Help-seeking had a significant positive relationship with procedural performance (0.41, p<.01), but not diagnostic performance

Authors’ Conclusions

• Rudeness harms the diagnostic and procedural performance of practitioners

Strengths

• Randomised controlled trial
• Blinding of experimenter, participants and assessors
• Use of videos allowed standardised process
• Moderate-to-high inter-rater reliability of judges
• Good baseline balance between groups of study participants (e.g. expertise and experience)
• If anything, the ‘rudeness’ was relatively mild and was not personally directed (comments were generic to Israel) yet still appeared to have a detrimental effect
• The study is underpinned by a persuasiveness conceptual framework explaining how rudeness affects performance
• Team member assignments were random, resembling the “flash teams” of people that may not have previously worked together that are common in hospital emergency responses

Weaknesses

• Randomisation process not clearly stated i.e was a computer random number generator used, or did the research assistant just pick?
• Sample size calculation, demonstrating power of study, was not performed
• Clinical expertise and training of judges in assessment was not specified
• It was not stated if the assessment process has been validated
• Although the findings of decreased performance were clearly statistically significant, the potential clinical significance of the deterioration in performance is uncertain
• Effects seen in this simulated setting may differ from what would occur ‘in real life’
• Study performed in a single country – staff in Israel may respond differently to rude behavior compared with staff in England

The Bottom Line

• This randomised controlled trial demonstrated that rudeness was associated with significantly reduced diagnostic and procedural performance
• Rudeness was significantly associated with
  • Reduced information sharing which in turn was associated with reduced diagnostic performance
  • Reduced help-seeking behaviour, which in turn was associated with reduced procedural performance
• There are limitations in the methodology of this paper, however, this is the best available evidence. We should therefore consider rudeness to be a patient safety issue and aim to minimise this behaviour

External Links

• [article] The impact of rudeness on medical team performance
• [further reading] St. Emlyns Journal Club
• [further listening] EmCrit – Rudeness: The Brindley Sessions

Metadata

Summary author: @davidslessor
Summary date: 25.07.18.
Peer-review editor: @precordialthump (Chris Nickson)