Development of Survey Scales for Measuring Exposure and Behavioral Responses to Disruptive Intraoperative Behavior.

OBJECTIVES: Disruptive intraoperative behavior has detrimental effects to clinicians, institutions, and patients. How clinicians respond to this behavior can either exacerbate or attenuate its effects. Previous investigations of disruptive behavior have used survey scales with significant limitations. The study objective was to develop appropriate scales to measure exposure and responses to disruptive behavior. METHODS: We obtained ethics approval. The scales were developed in a sequence of steps. They were pretested using expert reviews, computational linguistic analysis, and cognitive interviews. The scales were then piloted on Canadian operating room clinicians. Factor analysis was applied to half of the data set for question reduction and grouping. Item response analysis and theoretical reviews ensured that important questions were not eliminated. Internal consistency was evaluated using Cronbach α. Model fit was examined on the second half of the data set using confirmatory factor analysis. Content validity of the final scales was re-evaluated. Consistency between observed relationships and theoretical predictions was assessed. Temporal stability was evaluated on a subsample of 38 respondents. RESULTS: A total of 1433 and 746 clinicians completed the exposure and response scales, respectively. Content validity indices were excellent (exposure = 0.96, responses = 1.0). Internal consistency was good (exposure = 0.93, responses = 0.87). Correlations between the exposure scale and secondary measures were consistent with expectations based on theory. Temporal stability was acceptable (exposure = 0.77, responses = 0.73). CONCLUSIONS: We have developed scales measuring exposure and responses to disruptive behavior. They generate valid and reliable scores when surveying operating room clinicians, and they overcome the limitations of previous tools. These survey scales are freely available.

Prevalence and predictors of exposure to disruptive behaviour in the operating room.

PURPOSE: Disruptive intraoperative behaviour ranges from incivility to abuse. This behaviour can have deleterious effects on clinicians, students, institutions, and patients. Previous investigations of this behaviour used underdeveloped tools or small sampling frames. We therefore examined the prevalence and predictors of perceived exposure to disruptive behaviour in a multinational sample of operating room clinicians. METHODS: A total of 134 perioperative associations in seven countries were asked to distribute a survey examining five types of exposure to disruptive behaviour: personal, directed toward patients, directed toward colleagues, directed toward others, or undirected. To compare the average amount of exposure with each type, we used a Friedman's test with select post hoc Wilcoxon tests. A negative binomial regression model identified socio-demographic predictors of personal exposure. RESULTS: Of the 134 organizations approached, 23 (17%) complied. The total response rate was estimated to be 7.6% (7465/101,624). Almost all (97.0%; 95% confidence interval [CI], 96.6 to 97.4) of the respondents reported exposure to disruptive behaviour in the past year, with the average respondent experiencing 61 incidents per year (95% CI, 57 to 65). Groups reporting higher personal exposure included clinicians who were young, inexperienced, female, non-heterosexual, working as nurses, or working in clinics with private funding (all P < 0.05). CONCLUSION: Perceived exposure to disruptive behaviour was prevalent and frequent, with the most common behaviours involving speaking ill of clinicians and patients. These perceptions, whether accurate or not, can result in detrimental consequences. Greater efforts are required to eliminate disruptive intraoperative behaviour, with recognition that specific groups are more likely to report experiencing such behaviours.

RéSUMé: OBJECTIF: Les comportements perturbateurs en salle d'opération vont de l'incivilité à l'abus. Ce type de comportement peut avoir des effets délétères sur les cliniciens, les étudiants, les institutions et les patients. Les études précédentes de ce type de comportement se sont servies d'outils sous-développés ou de cadres d'échantillonnage restreints. Nous avons donc examiné la prévalence et les prédicteurs d'une exposition perçue à un comportement perturbateur dans un échantillon multinational de cliniciens de salle d'opération. MéTHODE: Au total, on a demandé à 134 associations périopératoires issues de sept pays de distribuer un sondage examinant cinq types d'exposition à des comportements perturbateurs : personnel, dirigé vers les patients, dirigé vers des collègues, dirigé vers les autres, ou non dirigé. Afin de comparer le nombre moyen d'expositions à chacun de ces types de comportement, nous avons utilisé un test de Friedman accompagné d'une sélection de tests de Wilcoxon réalisés post-hoc. Un modèle de régression binomiale négative a identifié les prédicteurs sociodémographiques d'exposition personnelle. RéSULTATS: Parmi les 134 organismes contactés, 23 (17 %) ont accepté de distribuer le sondage. Le taux de réponse total était estimé à 7,6 % (7465/101 624). Presque tous (97,0 %; intervalle de confiance [IC] 95 %, 96,6 à 97,4) les répondants ont rapporté avoir été exposés à des comportements perturbateurs au cours de l'année précédente, un répondant moyen subissant 61 incidents par année (IC 95 %, 57 à 65). Parmi les groupes rapportant une exposition personnelle plus élevée, les jeunes cliniciens, ceux avec peu d'expérience, les femmes, les non-hétérosexuels, le personnel infirmier ou les personnes travaillant dans des cliniques privées (tous P < 0,05) ont été identifiés. CONCLUSION: L'exposition perçue à des comportements perturbateurs était élevée et fréquente, les comportements les plus souvent rapportés étant la médisance à l'égard des cliniciens ou des patients. Ces perceptions, qu'elles soient vraies ou non, peuvent entraîner des conséquences délétères. Des efforts plus importants sont nécessaires afin d'éliminer les comportements perturbateurs en salle d'opération, en reconnaissant que certains groupes vulnérables sont plus à risque de rapporter avoir subi de tels comportements.

The Appropriateness of Language Found in Research Consent Form Templates: A Computational Linguistic Analysis.

BACKGROUND: To facilitate informed consent, consent forms should use language below the grade eight level. Research Ethics Boards (REBs) provide consent form templates to facilitate this goal. Templates with inappropriate language could promote consent forms that participants find difficult to understand. However, a linguistic analysis of templates is lacking. METHODS: We reviewed the websites of 124 REBs for their templates. These included English language medical school REBs in Australia/New Zealand (n = 23), Canada (n = 14), South Africa (n = 8), the United Kingdom (n = 34), and a geographically-stratified sample from the United States (n = 45). Template language was analyzed using Coh-Metrix linguistic software (v.3.0, Memphis, USA). We evaluated the proportion of REBs with five key linguistic outcomes at or below grade eight. Additionally, we compared quantitative readability to the REBs' own readability standards. To determine if the template's country of origin or the presence of a local REB readability standard influenced the linguistic variables, we used a MANOVA model. RESULTS: Of the REBs who provided templates, 0/94 (0%, 95% CI = 0-3.9%) provided templates with all linguistic variables at or below the grade eight level. Relaxing the standard to a grade 12 level did not increase this proportion. Further, only 2/22 (9.1%, 95% CI = 2.5-27.8) REBs met their own readability standard. The country of origin (DF = 20, 177.5, F = 1.97, p = 0.01), but not the presence of an REB-specific standard (DF = 5, 84, F = 0.73, p = 0.60), influenced the linguistic variables. CONCLUSIONS: Inappropriate language in templates is an international problem. Templates use words that are long, abstract, and unfamiliar. This could undermine the validity of participant informed consent. REBs should set a policy of screening templates with linguistic software.

Participation of Canadian anesthesiology departments in undergraduate medical education.

PURPOSE: Historically, anesthesiology departments have played a small role in teaching the pre-clerkship component of undergraduate medical education (UGME). The purpose of this study was to measure the current participation of Canadian anesthesiologists in UGME with a focus on pre-clerkship. METHODS: Three surveys were developed in collaboration with the Association of Canadian Departments of Anesthesia. After an initial series of validation procedures, the surveys were distributed to anesthesia department heads, UGME directors, and associate deans at the 17 Canadian medical schools. RESULTS: The median [interquartile range (IQR)] percentage of anesthesiologists with teaching roles in pre-clerkship was 10.0 [3.4-21]%. The median [IQR] hours taught per anesthesiologist during pre-clerkship was 2.2 [0.4-6.1] hr·yr-1, representing an 817% increase over the last 15 years. Eleven of 17 departments contributed at a level less than expected based on their proportional faculty size, and 6 of 17 departments contributed less than 1% of pre-clerkship hours. Anesthesiology departments thought more strongly than associate deans that their contributions were limited by a lack of teaching opportunities (P = 0.01) and that their contributions were indispensable (P = 0.033). Only 12 of 17 schools had mandatory anesthesia clerkships, with a median [IQR] duration of 10 [10-11] days. CONCLUSION: The contribution of anesthesiology departments to pre-clerkship has increased over the past fifteen years but remains much less than expected based on proportional faculty size. While the increase is encouraging, the relatively poor engagement is concerning, representing not only a missed opportunity but also a possible threat to the academic standing of the profession.

Disruptive behaviour in the perioperative setting: a contemporary review.

PURPOSE: Disruptive behaviour, which we define as behaviour that does not show others an adequate level of respect and causes victims or witnesses to feel threatened, is a concern in the operating room. This review summarizes the current literature on disruptive behaviour as it applies to the perioperative domain. SOURCE: Searches of MEDLINE®, Scopus™, and Google books identified articles and monographs of interest, with backreferencing used as a supplemental strategy. PRINCIPAL FINDINGS: Much of the data comes from studies outside the operating room and has significant methodological limitations. Disruptive behaviour has intrapersonal, interpersonal, and organizational causes. While fewer than 10% of clinicians display disruptive behaviour, up to 98% of clinicians report witnessing disruptive behaviour in the last year, 70% report being treated with incivility, and 36% report being bullied. This type of conduct can have many negative ramifications for clinicians, students, and institutions. Although the evidence regarding patient outcomes is primarily based on clinician perceptions, anecdotes, and expert opinion, this evidence supports the contention of an increase in morbidity and mortality. The plausible mechanism for this increase is social undermining of teamwork, communication, clinical decision-making, and technical performance. The behavioural responses of those who are exposed to such conduct can positively or adversely moderate the consequences of disruptive behaviour. All operating room professions are involved, with the rank order (from high to low) being surgeons, nurses, anesthesiologists, and "others". The optimal approaches to the prevention and management of disruptive behaviour are uncertain, but they include preventative and professional development courses, training in soft skills and teamwork, institutional efforts to optimize the workplace, clinician contracts outlining the clinician's (and institution's) responsibilities, institutional policies that are monitored and enforced, regular performance feedback, and clinician coaching/remediation as required. CONCLUSIONS: Disruptive behaviour remains a part of operating room culture, with many associated deleterious effects. There is a widely accepted view that disruptive behaviour can lead to increased patient morbidity and mortality. This is mechanistically plausible, but more rigorous studies are required to confirm the effects and estimate their magnitude. An important measure that individual clinicians can take is to monitor and control their own behaviour, including their responses to disruptive behaviour.

Appropriateness of Language Used in Patient Educational Materials from 24 National Anesthesiology Associations.

BACKGROUND: Patient education materials produced by national anesthesiology associations could be used to facilitate patient informed consent and promote the discipline of anesthesiology. To achieve these goals, materials must use language that most adults can understand. Health organizations recommend that materials be written at the grade 8 level or less to ensure that they are understood by laypersons. The authors, therefore, investigated the language of educational materials produced by anesthesiology associations. METHODS: Educational materials were downloaded from the Web sites of 24 national anesthesiology associations, as available. Materials were divided into eight topics, resulting in 112 separate passages. Linguistic measures were calculated using Coh-Metrix (version 3.0; Memphis, USA) linguistic software. The authors compared the measures to a grade 8 standard and examined the influence of both passage topic and country of origin using multivariate ANOVA. RESULTS: The authors found that 67% of associations provided online educational materials. None of the passages had all linguistic measures at or below the grade 8 level. Linguistic measures were influenced by both passage topic (F = 3.64; P < 0.0001) and country of origin (F = 7.26; P < 0.0001). Contrast showed that passages describing the role of anesthesiologists in perioperative care used language that was especially inappropriate. CONCLUSIONS: Those associations that provided materials used words that were long and abstract. The language used was especially inappropriate for topics that are critical to facilitating patient informed consent and promoting the discipline of anesthesiology. Anesthesiology associations should simplify their materials and should consider screening their materials with linguistic software before making them public.