Abstract
Objective: To understand the effect of an uncivil environment on the
performance of an obstetric team with a focus on non-technical skills,
and to ascertain whether simulation training can be used to demonstrate
the impact of incivility.
Design: An interventional, simulation study.
Setting: Wessex Deanery School of Obstetrics and Gynaecology (O&G), UK.
Population or Sample: O&G trainees.
Methods: Ethical approval was received from the University of
Southampton Research Ethics Committee (81008). Following informed
consent, twenty three trainees observed two simulated scenarios of the
management of a postpartum haemorrhage (PPH) and completed a Team
Emergency Assessment Measure (TEAM) questionnaire for each simulation.
In the first scenario the anaesthetist was civil and in the second
uncivil. ANOVA was used for statistical analysis, p values of
<0.05 were considered statistically significant.
Main Outcome Measures: TEAM observation questionnaire domains of
leadership, teamwork and team management.
Results: There was a significant reduction in the overall team
performance in an uncivil environment compared to a civil one (p=0.006).
The biggest differences in scores were observed in team morale
(4.00/4.00 in the civil versus 2.22/4.00 in the uncivil simulation,
p<0.001) and effective communication (4.00/4.00 in the civil
versus 2.22/4.00 in the uncivil simulation, p<0.001).
Conclusions: Incivility affects the ability of the multi-disciplinary
team to effectively manage an obstetric emergency and simulation is an
effective tool to demonstrate the impact of poor workplace behaviours.
Funding: AJK is funded by the NIHR Clinical Lecturer scheme, HP was in
post as a simulation fellow funded by the Wessex deanery. No other
funding was received for this project.
Keywords: Human Factors, Teamwork, Civility, Simulation, Obstetrics
Background
Civility is an important element of team-working, with uncivil
interactions known to negatively affect the performance of healthcare
professionals1. Incivility can range from just
ignoring someone, to being overtly rude or
aggressive1. In the 2023 General Medical Council
(GMC)2 survey, over a quarter of trainees said they
had experienced micro-aggressions, negative comments or oppressive body
language from colleagues, with Obstetrics & Gynaecology (O&G) being
the second highest specialty experiencing this type of behaviour. In the
same study, 16% of O&G trainees (the highest percentage of any
specialty) reported that they have been a victim of, or have witnessed
bullying or harassment in their post2. This ongoing
issue with uncivil behaviours within the UK O&G workforce was
highlighted in the recent Ockenden report3, which made
a national recommendation that all trusts must have training on
upholding civility in the workplace.
Incivility directly impacts an individual’s ability to function,
reducing cognitive ability by 61% and commitment to work by
78%4. The wider team can also be impacted and
witnesses of uncivil behaviour show a 20% decrease in performance, and
a 50% decrease in willingness to help others1. The
impact of incivility on team function has been studied in randomised
control trials. Katz et al.5 performed a multicentre,
randomised control trial exposing anaesthetic residents to either a
normal or rude environment during a simulated operating room crisis.
Incivility had a negative impact on overall performance as rated by
blinded observers looking at both technical and non-technical domains
such as vigilance, diagnosis and communication. Riskin et
al.6 performed a similar study. Neonatal Intensive
Care Unit (NICU) teams participated in simulations involving the acute
deterioration of a preterm infant. During the simulation, teams were
exposed to an expert who either provided rude comments or neutral
comments. The study demonstrated that teams exposed to rudeness
performed worse in diagnostic and procedural performance.
Teaching about civility plays an important role in increasing awareness
of the effect interpersonal behaviour has on team performance. To date,
no research has been performed to demonstrate the effect of team
civility in the high-risk environment of obstetrics. This study aims to
investigate whether simulation can be used to recreate civil and uncivil
workplace environments, and hence be used as a tool to demonstrate the
impact of incivility to O&G trainees.
Methods
Setting
Simulations took place during an O&G trainee teaching day held in the
simulation suite at University Hospital Southampton NHS Foundation
Trust, a large teaching hospital within the Wessex deanery. Trainees
were divided into two groups and attended either a morning or afternoon
session.
Intervention
Trainees in each group were asked to participate in two simulated
scenarios based on the clinical management of post-partum haemorrhage.
Two volunteers (a junior at specialty training level one to five and a
senior clinician at specialty training level six to seven) were asked to
play an active role in the scenarios. They were supported by the
simulation team consisting of an anaesthetist, a midwife, and a
healthcare assistant. The remaining trainees were asked to observe the
scenario via video-link and complete a Team Emergency Assessment Measure
(TEAM) observation questionnaire for each simulation.
A pre-brief occurred prior to the scenarios covering ground rules such
as confidentiality and detailing a safe learning environment to help
preserve individuals’ psychological safety within the scenarios.
The simulated team members were provided with a faculty brief to ensure
standardisation across the scenarios throughout the training day. In the
first scenario, the anaesthetist was instructed to be civil and helpful
when asked to play a role in managing the emergency. In the second
scenario, the anaesthetist was briefed to be uncivil, so was rude to
team members and obstructive to requests to help manage the emergency
scenario. The scenario lesson plan included example external stressors
that could be contributing to the anaesthetist’s incivility. This was to
encourage realistic responses rather than a caricature portrayal which
would decrease fidelity, change participants emotional reaction and
impact on depth of learning. A debrief followed each simulation
utilising the Dynamic-Delta-Plus model chosen for its
adaptability7. The model includes three key phases:
opening, plus-delta and summary phases. Unlike previous models the
Dynamic-Delta-Plus allows for reactions from participants to be explored
prior to breaking down the scenario into positive and development
learning points. This was therefore appropriate for use in an incivility
simulation as the educating team expected participants to experience an
emotional reaction to the scenarios. Allowing the opportunity to discuss
this first would aid in maintaining a safe psychological space when
debriefing an intentionally challenging scenario.
Recruitment
Ethical approval was obtained from the University of Southampton
Research Ethics Committee (ERGO number 81008). Convenience sampling was
utilised; all O&G trainees in the Wessex region who had attended the
regional teaching day were invited to participate in the study. No
trainees declined to take part in the study however, it was made clear
through the consent discussion and form that this would not have
impacted on their ability to take part in the teaching day.
Study design
This is an interventional simulation study with quantitative data
collected in the form of the validated TEAM questionnaire. This was
chosen to explore the effects simulated incivility has on non-technical
skills as observed by peers of the participants. The TEAM tool has
previously been validated in the use of obstetric and gynaecological
simulated emergencies by Carpini et al.8, confirming
that the tool has high convergent validity (0.75, P<0.001),
internal reliability (average alpha = 0.92) and excellent inter-rater
reliability (inter-class correlation coefficient 1 = 0.98).
Statistical analysis was performed using Microsoft Excel and SPSS
version 29 (IBM ARMONK, NY USA). ANOVA was used to compare the
individual question scores from the TEAM questionnaire between the civil
and uncivil scenarios. P values of less than 0.05 were considered
statistically significant.
Feedback
Following the teaching day, trainees were invited to complete an online
feedback form which asked ‘What is your takeaway message from today?’,
‘Did simulation aid your learning on civility in the workplace?’, ‘What
aspects of the day were most useful or valuable?’ and ‘How would you
improve this day?’.
Patient involvement
This is a study of healthcare practitioners only.
Results
Twenty-three O&G doctors participated in the study from specialty
training level one to seven. Trainees actively participating in the
simulations did not complete a TEAM observation questionnaire for the
scenario they were part of. All trainees were happy to partake in the
study and all participants signed the consent form prior to their
involvement.
Leadership
There was no significant effect demonstrated on the doctor’s ability to
lead the scenario when exposed to incivility, with observers stating
that the leader still communicated what was expected of the team (score
3.59/4.00 in civil simulation versus 3.39/4.00 uncivil simulation, p =
0.343) and maintained a global perspective (score 3.71/4.00 in civil
simulation versus 3.56/4.00 uncivil simulation, p = 0.372).
Teamwork
When managing a simulated obstetric emergency, incivility had the
greatest effect on the team’s ability to work together. Six out of the
seven headings under the teamwork category of the Team Emergency
Assessment Measure (TEAM) questionnaire demonstrated significant
differences in the uncivil environment compared to the civil one (Table
1). The greatest effect was demonstrated in having positive team morale
(score 4.00/4.00 in civil simulation versus 2.22/4.00 uncivil
simulation, p <0.001) and effective communication (score
4.00/4.00 in civil simulation versus 2.22/4.00 uncivil simulation, p
<0.001). There were also differences in the team’s ability to
complete tasks in a timely manner, adapt to changing situations and
anticipate potential actions.
Task Management
When managing a simulated obstetric emergency, incivility had no
significant effect on the team’s ability to follow approved standards
and guidelines (score 3.82/4.00 in civil simulation versus 3.56/4.00
uncivil simulation, however it did impair the team’s ability to
prioritise tasks effectively (score 3.71/4.00 in civil simulation versus
3.22/4.00 uncivil simulation, p 0.039).
Global score
Observers felt there was a significant difference in the overall team’s
performance in an uncivil environment compared to a civil one (score
9.06/10.00 in civil simulation versus 7.82/10.00 uncivil simulation, p
0.006).
Utilising simulation to demonstrate the impact of incivility
Eleven of the twenty-three trainees who attended the day opted to fill
in the feedback form. 100% of these trainees felt that simulation aided
their learning on civility in the workplace. Ten of the eleven trainees
chose to write a takeaway message from the day, and all of these
included either civility or calling out unacceptable behaviour in the
workplace. Comments on the most useful aspects of the day covered the
impact of discussing incivility with colleagues in the debriefs,
comparing the civil and uncivil scenarios,and that using simulation was
valuable.
‘Similarity of scenarios but not telling us the challenge was the
anaesthetist’s behaviour… so we had to work it out ourselves! More
powerful learning.’
‘Very insightful debriefs and discussions about the impact of uncivil
behaviours and importance of addressing them.’
Comments by trainees on improvements that could be made to the day
included having more simulation scenarios/sessions, having smaller
groups to encourage discussion, and timing responses within the
scenarios to see if there were any differences between civil and uncivil
environments.
‘To time the management milestones in both scenarios to prove that
different behaviours do affect performance.’
‘More sim sessions so more people can participate in the sim.’
Discussion
Main findings
To our knowledge, this is the first study examining the use of
simulation for demonstrating the impact of incivility to O&G trainees.
The results of our interventional simulation study demonstrate that
incivility in a simulated environment affects the ability of the
multi-disciplinary team to effectively manage an obstetric emergency. On
examining the components of the TEAM questionnaire, there was
significant reduction in scores related to team-working capability in
six of the seven domains. There was no statistically significant
difference in the leadership proficiency of the obstetric doctors as
observed by their colleagues. The final component, task management,
demonstrated a reduction in scores relating to prioritisation of tasks
in the uncivil environment but no change in ability to follow approved
standards and guidelines.
Strengths and Limitations
A strength of our study was the crossover study design that allowed for
participants to be their own controls. This study utilised a validated
questionnaire that is regularly used in the research of simulation in
emergency settings9,10. This study created a high
fidelity simulated environment by utilising a labour ward set up
simulation suite with key members of the multi-disciplinary team acting
within their own job roles. The simulation was also streamed via
video-link to observers so as to not disrupt in room realism for the
participants. All members of the multi-disciplinary simulation team
remained in their roles across all of the scenarios therefore
maintaining standardisation for each of the participants.
The primary limitation of this study is that it was undertaken in a
single UK region, on a single training day. The chosen simulated
scenario was a post-partum haemorrhage. This was chosen to help protect
the psychological safety of the participants as it is a common labour
ward emergency that O&G doctors should be competent in managing.
Therefore learning and teaching could be directed at the non-technical
skills surrounding the scenario. However, it is recognised that there
may be different findings if alternative, less common clinical scenarios
were utilised. A further limitation is that convenience sampling was
used and is therefore open to volunteer bias.
Interpretation
This study demonstrates that simulation can be used to demonstrate the
impact of incivility to O&G trainees, as all attendees who provided
feedback for the day felt that simulation aided their learning about
civility in the workplace. This suggests that this teaching tool is an
appropriate method for this cohort of healthcare professionals. In
addition, eight of the twelve domains within the TEAM tool were observed
by peers to be significantly different in the civil versus uncivil
scenarios. This shows that simulation can recreate an uncivil
environment to the extent that it affects a team’s performance as it
would do in a real-world setting. This is especially important as it
would be unethical to purposely create an uncivil environment in a
real-world healthcare environment given the effect it could have on
patient outcomes and the ability to provide adequate psychological
safety to learners.
The study demonstrated a significant negative effect in team working
through exposure to incivility. Morale, effective communication,
completion of tasks, adaptation to changing situations and
prioritisation of tasks were all affected. This is reflected in the
study of Riskin et al.6, who found that rudeness
lowered information-sharing and help-seeking in their NICU teams, and
helped to explain their drop in diagnostic performance. The Riskin et
al.6 study specifically looked at clinical elements of
the simulated scenarios such as ‘diagnosed respiratory distress’ and
‘performed resuscitation well’. This study did not explore specific
clinical aspects of the scenarios and the effect incivility could have
on these. Our findings demonstrated no significant difference in ability
to follow standard procedures and protocols. This could be due to
post-partum haemorrhage being a routine obstetric emergency with regular
mandatory simulated practice for maternity staff in the
UK3. Further research is needed to explore if
incivility has a greater effect on less common obstetric emergencies
where protocols are less well rehearsed by trainees and the wider MDT.
The TEAM tool also did not allow for exploration of the time taken to
implement standard protocols. Although overall there was no difference
between the civil and uncivil environments demonstrated in this study,
we hypothesise that the time taken to instigate these protocols could be
different and would be critical to understand for ongoing patient safety
in obstetric emergencies.
This study demonstrated no significant difference in observed leadership
abilities in civil compared with uncivil simulated environments. Katz et
al.5 explored the performance of anaesthesiology
residents in similar simulated surgical settings. They found a
significant difference in performance as rated by observers (91% in
control group versus 63.6% in experimental group). However
self-reported ratings of individual performance did not differ between
the two groups. This study did not ask participants to rate their own
performance in the scenarios. Future research could therefore
investigate if obstetric trainees similarly felt their performance
unaffected by incivility. Having insight into the effects incivility has
on performance is important for clinical staff as this will enable them
to recognise effects on their cognition and implement tools to minimise
impacts on clinical outcomes. This study utilised peer observers to
complete the TEAM questionnaire therefore further study could
investigate whether independent raters, such as obstetric consultants,
had a different opinion on whether clinical performance was affected
comparing the two environments.
Conclusion
Incivility has a significant effect on team working in simulated
obstetric emergency scenarios, with effective communication and positive
team morale being the most affected elements. Incivility did not
negatively affect O&G trainees’ leadership ability as reported by peer
observers. Simulation is an effective tool for demonstrating the impact
of incivility to O&G trainees.
Research recommendations
- Simulate less commonly occurring obstetric emergencies to understand
if incivility has a greater effect in these scenarios.
- Research effect incivility has on time taken to enact key treatment
protocols in obstetric simulations.
- Explore self-reported effects of incivility simulation on individual
trainee performance.
- Independent assessment of performance of O&G trainees in simulated
uncivil environments to assess effect on both technical and
non-technical skills.
Author contributions
HP conceived the idea, designed the study, conducted data collection and
wrote the manuscript. EC, MD, LG & JB were part of the MDT running the
intervention and aided with data collection. GV aided with study
conception and supervision of the study. AK aided with design of study,
performed the data collection, wrote up the manuscript and supervised
the study. All authors edited and approved the final manuscript.
Conflict of interest
No conflicts declared.
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