Expressions of Gratitude and Medical Team Performance Arieh Riskin, MD, MHA,a,b,c Peter Bamberger, PhD,a Amir Erez, PhD,d Kinneret Riskin-Guez, BSc,e Yarden Riskin,f Rina Sela, CCRN, MA,g Trevor Foulk, PhD,h Binyamin Cooper, MA,d Amitai Ziv, MD, MHA,g,i Liat Pessach-Gelblum, MBA,g Ellen Bamberger, MDc,j

BACKGROUND AND OBJECTIVES: Exposure to negative social interactions (such as rudeness) has robust abstract adverse implications on medical team performance. However, little is known regarding the effects of positive social interactions. We hypothesized that expressions of gratitude, a prototype of positive social interaction, would enhance medical teams’ effectiveness. Our objective was to study the performance of NICU teams after exposure to expressions of gratitude from alternative sources. METHODS: Forty-three NICU teams (comprising 2 physicians and 2 nurses) participated in training workshops of acute care simulations. Teams were randomly assigned to 1 of 4 conditions: (1) maternal gratitude (in which the mother of a preterm infant expressed gratitude to NICU teams, such as the one that treated her child), (2) expert gratitude (in which a physician expert expressed gratitude to teams for participating in the training), (3) combined maternal and expert gratitude, or (4) control (same agents communicated neutral statements). The simulations were evaluated (5-point Likert scale: 1 = failed and 5 = excellent) by independent judges (blind to team exposure) using structured questionnaires. RESULTS: Maternal gratitude positively affected teams’ performances (3.9 6 0.9 vs 3.6 6 1.0; P = .04), with most of this effect explained by the positive impact of gratitude on team information sharing (4.3 6 0.8 vs 4.0 6 0.8; P = .03). Forty percent of the variance in team information sharing was explained by maternal gratitude. Information sharing predicted team performance outcomes, explaining 33% of the variance in diagnostic performance and 41% of the variance in therapeutic performance. CONCLUSIONS: Patient-expressed gratitude significantly enhances medical team performance, with much of this effect explained by enhanced information sharing.

’ aColler School of Management and iSackler Faculty of Medicine, University, Ramat Aviv, ; WHAT S KNOWN ON THIS SUBJECT: Exposure to benign bDepartments of Neonatology and jPediatrics, Bnai Zion Medical Center, , Israel; cRappaport Faculty of negative social interactions, such as rudeness, has Medicine, Technion Israel Institute of Technology, Haifa, Israel; dWarrington College of Business, University of a robust adverse effect on medical team performance. Florida, Gainesville, Florida; eGoldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the However, little is known regarding the effects of positive f g Negev, Beer Sheva, Israel; Interdisciplinary Center , Herzliya, Israel; Israel Center for Medical Simulation, social interactions on medical teams or teams more Chaim , Tel HaShomer, , Israel; and hRobert H. Smith School of Business, generally. University of Maryland, College Park, Maryland

Drs Riskin and Bamberger conceptualized and designed the study, conducted the initial analyses, WHAT THIS STUDY ADDS: Expressions of gratitude and drafted the initial manuscript; Dr Erez conceptualized and designed the study, enhanced the effectiveness of medical teams. Although coordinated data collection, and critically reviewed the manuscript; Mrs Riskin-Guez, Ms Riskin, expressions of gratitude stemming from a senior and Ms Sela designed the data collection instruments, coordinated and supervised data collection, colleague were not recognized as such, those stemming and critically reviewed the manuscript; Dr Foulk, Mr Cooper, Dr Ziv, Ms Pessach-Gelblum, from patients or their families were impactful, boosting and Dr Bamberger designed the study, coordinated data collection, and critically reviewed the information sharing and enhancing performance manuscript; and all authors approved the final manuscript as submitted and agree to be outcomes. accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2018-2043 To cite: Riskin A, Bamberger P, Erez A, et al. Expressions of Gratitude and Medical Team Performance. Pediatrics. Accepted for publication Dec 28, 2018 2019;143(4):e20182043

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 4, April 2019:e20182043 ARTICLE Recent evidence reveals that social patient or the patient’s family situational constraints, and executing interactions in medicine have robust member) but not if gratitude is procedures in a timely and implications on the performance of expressed to them by someone filling error-free manner). Additionally, medical teams and their members.1,2 a different role (eg, supervisor or and consistent with research These interactions need not be expert).4,5 Finally, even if gratitude is demonstrating that patient-focused extreme in nature. In fact, studies inferred by medical staff, it may have communications motivate reveal that being exposed to no net positive effect on performance practitioners better than those rudeness, a benign form of incivility, if, as suggested by the affect-as- focused on the practitioners has adverse consequences on both information theory, it drives the themselves,23 we tested the degree to individual and team diagnostic and gratitude recipients to feel which maternal gratitude would have treatment performance, accounting overconfident and rely on more different effects on team diagnosis for more of the variance in such automatic modes of information and treatment compared with outcomes than the presence or processing when conditions require gratitude stemming from an authority absence of computerized order entry more reflective thinking.6,7 figure (ie, expert). Finally, as depicted systems or practitioner sleep in Fig 1, we examined the degree to On the other hand, psychologists have deprivation combined.1,2 which the effect of gratitude on team consistently demonstrated that Nevertheless, given the intense and performance could be explained by positive communication and high-stakes environments in which its effect on 2 main synergistic team interpersonal interactions have medical teams operate, rudeness may processes, namely information a positive impact on individual be difficult to prevent or constrain. – sharing and workload sharing. In affect.8 10 In turn, positive affect has After all, it is precisely in such summary, we sought to offer some been shown to improve individual contexts that individuals’ self- initial insights into the degree to performance by enhancing regulatory resources are most rapidly which expressions of gratitude link to individuals’ problem solving and depleted, making it difficult for – medical team performance and decision-making abilities9,11 15 and practitioners and patients alike to explicate the mechanisms underlying by facilitating thinking that is more avoid remarks that others might any such possible effects. flexible,16 creative,17,18 integrative,19 perceive as rude, if not threatening or open,20 forward-looking and high- abusive.3 level,21 and efficient.19 Such effects METHODS But what if efforts were made to could potentially drive enhanced For a detailed description of the encourage patients and medical staff team diagnostic and treatment procedures and measures used, please to consciously engage in more performance to the extent that they refer to the Supplemental Information. positive interpersonal relating, such lead medical staff to more efficiently as expressing gratitude? Given that integrate ideas voiced by others as Participants rudeness, a mild form of incivility, well as better anticipate, recognize, Applying the same experimental and respond to the information and/ depletes the cognitive resources design that was used to study the or assistance needs that those in 1,2 required for effective team work effects of incivility, 43 NICU teams, 1,2 other roles may have at any given among medical professionals, each comprising 2 physicians and 2 point in time.9,22 might expressions of gratitude, nurses, were recruited from among a widely prevalent form of civil Accordingly, the current study was the various NICUs operating in behavior, have restorative effects, designed to examine whether and Israel’s hospitals. The study was resulting in enhanced team how expressions of gratitude approved by the Ethics Committee of performance? stemming from individuals Tel Aviv University and by the Chaim On the one hand, the likelihood of any representing different roles affect the Sheba Medical Center Institutional beneficial effect may be small, in that performance of ICU teams. We Review Board. All participants gave expressions of gratitude are typically examined 2 main dimensions of informed consent before taking part. brief and subtle forms of positive medical team performance, namely interaction, suggesting that medical diagnosis (requiring the ability of the Settings staff will likely pay little if any team to integrate and synthesize Teams were offered the opportunity attention to them. Moreover, role- disparate pieces of information in to join a full medical simulation specific expectations may lead the a timely manner), and treatment training day at the Israel Center for same individual to infer gratitude and (requiring the ability of the team to Medical Simulation (MSR) at Chaim draw positive inferences from identify the correct protocol for Sheba Medical Center. The espoused gratitude statements expressed to addressing the problem diagnosed, purpose of the exercise was to train them by a person filling 1 role (eg, adjusting the intervention to meet teams in debriefing techniques,24 as

Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 RISKIN et al the basis of conventional protocol, the main actions required from the medical team were detailed for each scenario and distributed to independent judges (senior neonatologists and veteran nurses) to facilitate their monitoring and evaluation. The scenarios involved diagnostic and manual intervention skills and required that members engage with one another in making and executing therapeutic decisions. After each simulation, the team FIGURE 1 entered a separate room for Hypothesized path model of the effect of maternal gratitude on team performance, mediated by areflexivity-based debriefing (ie, self- team processes. The solid line represents supported by data and the dashed line represents the reflection and debriefing). Before the nonsignificant path. start of the reflexivity exercise, the judges were asked to complete a means by which to facilitate team during the day. Regardless of a questionnaire in which they graded learning and enhance performance. condition, the day comprised 4 the participants’ performance. Aside emergency scenarios in neonatal from the manipulations noted above Procedure medicine, which represented (ie, gratitude versus control Four teams were recruited for each a diverse set of acute clinical conditions), the procedures were simulation day. NICU teams situations used to challenge the identical to that used in our previous participated in a training workshop, teams’ diagnostic performance as research on the implications of including simulations of acute care of well procedural skills. The social incivility in medical teams.1,2 term and preterm newborns interaction (gratitude or neutral (advanced medical manikins). statement) occurred before the Measures Participants were informed that beginning of the series of scenarios. Two independent NICU staff (1 senior a foreign expert would observe them The scenarios occurred in random doctor and 1 experienced nurse) who and that they would interact with order. In each scenario, the were blinded to the experimental actors posing as parents. Teams were participants were told that the NICU intervention observed each team’s randomly assigned to either exposure manikin lying in the incubator was performance in each of the simulation to gratitude (in which the expert their patient and that the patient’s scenarios from an adjacent control expressed gratitude to the team and/ vitals would appear on the monitors room with 1-way mirrors and or a mother of a preterm infant immediately after the start of the multiple video monitors that allowed expressed gratitude to NICU teams, simulation. Additionally, the for close-up observation and such as the one that saved her child) participants were provided with the monitoring of the patient’s vital signs. or the control (neutral statements neonate’s medical history. They were Before serving in that capacity, all regarding the increasing use of also informed that they may judges had a day-long training debriefings as a team learning tool encounter professional actors playing program used to emphasize the and the need to complete study parents of their patient and, if so, monitoring and assessment of the questionnaires) presented in a video were asked to interact with and team (rather than individual clip at the beginning of the day. For respond to them as they would in real members) as the unit of analysis. To the exact protocol used in each life. Additionally, participants were enhance interrater reliability, as part condition, please see the transcript in asked to work as a team and received of this training, descriptors and the Supplemental Information. After 20 to 25 minutes to discuss and examples of indicative behaviors signing informed consent forms in develop a treatment plan for each were presented to the judges and which it was indicated that the clinical scenario. Specifically, the team discussed by them to ensure that all purpose of our study was to enhance was required to identify the acute had a common understanding of their the understanding of how contextual deterioration in the infant’s condition meaning and application. For each factors influence medical outcomes, and respond promptly by providing scenario, using the same 5-point participants were briefed on the the appropriate resuscitative Likert scales (1 = failed; 5 = excellent) debriefing exercise to occur after the treatments while trying to diagnose used in our research on incivility in conclusion of each of the simulations the underlying medical condition. On medical teams,1,2 judges

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 4, April 2019 3 independently rated each team’s of agreement among multiple raters. gratitude (P . .10). When the performance along items relating to Comparisons of the different manipulation involved both mother parameters separated into 2 broad performance scores in the gratitude and expert, it was effective in aspects of team performance, namely and control groups were done by generating higher perceptions of diagnostic performance and using nonparametric tests: Kruskal- maternal gratitude (4.7 6 0.4) treatment (procedural) performance. Wallis 1-way ANOVA on ranks for relative to those in the control group The judges also assessed teams’ multiple comparisons and (P , .05) but not of expert gratitude. engagement in prosocial behavior on Mann–Whitney rank sum test on Given the nonsignificant the basis of the same measures used medians for comparison of 2 groups. manipulations involving the expert, to tap information sharing25 and Statistical significance was set at .05. we focused our statistical analyses on workload sharing26 in our previous Multivariate analyses were conducted the effects of maternal gratitude only. rudeness research.1,2 Judges were by using MPlus (version 7.2; Muthén provided with workbooks in which & Muthén, Los Angeles, CA), Our findings regarding the direct the parameters of each scenario were which is specifically designed to test impact of maternal gratitude on team detailed, with space in the margins path models and assess the degree processes and performance outcomes intentionally left blank to allow them to which the effect of an exogenous are displayed in Table 2. The findings to record their observations as they variable on some endogenous reveal that maternal gratitude had monitored team processes and variable may operate through some positive direct effects on overall performance. Agreement between intermediary mechanism (ie, therapeutic and procedural each team’s 2 raters on each of these magnitude and significance of performance (for both outcomes: 6 measures was sufficient (Rwg . 0.75) indirect effects). Because indirect control = 3.6 1.0 versus to justify the aggregation of judges’ effects have a skewed distribution, we maternal = 3.9 6 0.9; P , .05 for ratings by team. used a 2000 iteration resampling therapeutic and P , .01 for approach (Monte Carlo method) to procedural) as well as on the team Manipulation Check estimate indirect effects and their processes of information and To test the validity of the 95% confidence intervals (CIs).30 workload sharing (for both outcomes: manipulation, we conducted analysis control = 4.0 6 0.8 versus of variance (ANOVA), with gratitude maternal = 4.3 6 0.8; P , .05) but conditions as the independent RESULTS not on diagnostic performance. variable and perceived gratitude of To ensure that our randomization the confederate (assessed on the process of assigning teams to A preliminary examination of the basis of a modified measure adapted conditions was appropriate, we first effects of the gratitude manipulation from related measures in previous tested whether the age and over the course of the day reveals research27–29) as the dependent cumulative experience (in medicine that the expression of gratitude had variable. and neonatology) of the team’s its greatest impact on performance at members was distributed equally the outset, with groups exposed to Statistical Analysis across the conditions. We conducted maternal gratitude manifesting Because judges assessed team (rather an ANOVA with the conditions (eg, significantly higher mean procedural than individual team member) control, gratitude by expert, gratitude and general therapeutic scores processes and performance, all by mother, and gratitude by both) as in the first simulation after the analyses were conducted at the team the factor and the age or team intervention compared with the level by using SigmaPlot version 11.0 experience (ie, number of years in groups exposed to a neutral mother (Systat Software Inc, San Jose, CA) medicine or neonatology) as the (3.7 6 0.8 vs 2.9 6 1.1 [P = .007] and and Minitab version 16.2.2 (Minitab dependent variable. The results 3.7 6 0.9 vs 3.0 6 0.9 [P = .03], Inc, State College, PA) unless showed that there were no significant respectively). Moreover, whereas the otherwise indicated. A power analysis differences between the conditions, gratitude-exposed groups manifested based on data from a previous indicating that the randomization a moderate and relatively steady study1,2 and assuming a desired process had been successful improvement in performance over power of 80% with a of .05 (2-sided (Table 1). Examination of the ANOVA- the remaining 2 simulations, the test) revealed that samples of at least based manipulation checks presented pattern for the groups in the “mother- 9 teams per condition would be in Table 1 indicated that the neutral” (ie, control) groups was required to capture moderate effects. manipulation was effective with much less stable, with performance Because each team’s performance in respect to maternal gratitude (control = improving for simulation rounds 2 each of the scenarios was rated by 2 4.5 6 0.6 versus maternal = 4.8 6 and 3 before dropping precipitously judges, we assessed Rwg as a measure 0.4; P , .001) but not expert-based in the final simulation.

Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 RISKIN et al TABLE 1 Demographic Characteristics and Manipulation Checks Used to Assess the Effects of Gratitude in the Different Intervention Groups Evaluated Measure Control Expressions of Gratitude P Neutral Greeting, Mother and Expert, Mother Only (Expert-Neutral), Expert Only (Mother-Neutral), n =38 n =40 n =42 n =43 Age, mean 6 SD, y 37.0 6 8.2 36.3 6 7.6 37.6 6 7.4 35.5 6 5.5 .56 Male sex, % 17.9 22.5 13.9 27.9 .42 Occupational experience, mean 6 SD, y 9.0 6 9.3 8.1 6 9.2 10.0 6 9.4 7.1 6 6.9 .49 Experience in neonatology, mean 6 SD, y 6.9 6 8.6 6.2 6 8.6 7.7 6 8.1 4.6 6 5.5 .34 Manipulation check: expert, mean 6 SD 4.6 6 0.6 (4.9) 4.8 6 0.4 (5.0) 4.6 6 0.5 (4.8) 4.5 6 0.6 (4.8) .13 (median) Manipulation check: mother, mean 6 SD 4.5 6 0.6 (4.7)a 4.8 6 0.4 (5.0)b 4.7 6 0.4 (4.8)a,b 4.4 6 0.6 (4.6)b ,.001 (median) All comparisons of years were done by using 1-way ANOVA on means. Comparison of sex distribution among groups was done by using the x2 analysis. All the comparisons for the manipulation checks were done by using Kruskal-Wallis 1-way ANOVA on ranks because the distribution was not normal. The manipulation checks analyses were also conducted at the group or team level, and the results were equivalent. a Multiple comparisons between all pairs of groups revealed (by using Dunn’s method) that the significant differences (P , .05) were between the group exposed to expression of gratitude from both the expert and the mother and the control group. b Multiple comparisons between all pairs of groups revealed (by using Dunn’s method) that the significant differences (P , .05) were between the groups exposed to expression of gratitude from the mother or both the mother and the expert and the group exposed to expression of gratitude from the expert only.

Finally, we tested the mediating sharing, in explaining the effects of rudeness research, information processes through which mothers’ maternal gratitude on both outcomes. sharing served as a robust predictor gratitude might influence team More specifically, the indirect effect of of both team performance outcomes, diagnostic and therapeutic gratitude via information sharing on explaining 33% of the variance in performance. As shown in Fig 1, we diagnostic performance was 0.209 diagnostic performance and 41% of tested a path model in which (95% CI = 0.018 to 0.395; P = .03), the variance in therapeutic information sharing and workload and on procedural therapeutic performance. The indirect effect of sharing were both posited to mediate performance was 0.197 (95% gratitude via workload sharing was the effects of maternal gratitude on CI = 0.017 to 0.385; P = .04), Further not statistically significant. these 2 team performance outcomes. evidence of the mediating role of Although not shown in the figure (for information sharing is the fact that sake of simplicity), but reported in the direct effect of maternal gratitude DISCUSSION Table 3, the model also included the on these same outcomes contained Gratitude is omnipresent in social life, remaining direct (nonmediated) a 0 in the CI and was not statistically yet we know little about its fi effects of maternal gratitude on both signi cant in a model that included consequences on those being team performance outcomes. information sharing as a mediator. In thanked, no less on the performance terms of the magnitude of these of the teams of which they may be The findings presented in Table 3 effects, 40% of the variance in team members. Indeed, the current study indicate support for the mediating information sharing was explained by represents 1 of the first to examine role of only 1 of these 2 team maternal gratitude, and consistent the impact of gratitude from fi processes, namely information with the ndings in our earlier alternative sources on medical team performance and the mechanisms TABLE 2 Effects of Exposure to Expressions of Gratitude From the Mother of a Preterm Infant on potentially underlying such a link. Medical Team Performance Our findings reveal that members of Evaluated Measure No Gratitude From Mothera Gratitude From Motherb medical teams may be more sensitive N =22 N =21 P (Versus Control) to parental gratitude than to gratitude Diagnostic score 3.6 6 1.0 (4.0) 3.8 6 1.0 (4.0) .21 expressed by medical experts or 6 6 Therapy plan 3.6 1.0 (4.0) 3.9 0.9 (4.0) .08 authority figures. Indeed, whereas Procedural score 3.6 6 1.0 (4.0) 3.9 6 0.9 (4.0) .008 General therapeutic score 3.6 6 1.0 (4.0) 3.9 6 0.9 (4.0) .04 medical team members exposed to Confidence in diagnosis 3.7 6 1.1 (4.0) 3.8 6 1.1 (4.0) .38 maternal gratitude reported sensing Information sharing 4.0 6 0.8 (4.0) 4.3 6 0.8 (4.2) .03 gratitude on the part of that agent at Workload sharing 4.0 6 0.9 (4.0) 4.3 6 0.8 (4.5) .02 a level higher than that of those in the Assessments of performance and analysis were all done at the team level, thus N is the number of teams and not of control group (the group unexposed participants. Data are presented as mean 6 SD (median). All comparisons were done by using the Mann–Whitney rank to any gratitude), experts’ gratitude sum test because the distributions were not normal. a This control group includes the neutral group and the expert’s gratitude group. as sensed by those in the expert b The gratitude condition includes the mother and the mother and expert. manipulation condition was not

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 4, April 2019 5 TABLE 3 Standardized Coefficients for Mediation Model Explaining the Effects of Gratitude From the Mother on Different Aspects of Medical Teams Performance Information Sharing Workload Sharing Diagnostic Performance Procedural Performance Estimate 95% CI Estimate 95% CI Estimate 95% CI Estimate 95% CI Gratitude by mother +0.264* 0.016 to 0.488 +0.298* 0.024 to 0.534 20.046 20.304 to 0.197 +0.149 20.090 to 0.375 Information sharing ————+0.614** 0.375 to 0.853 +0.557** 0.327 to 0.795 Workload sharing ————+0.221 20.015 to 0.454 +0.626 20.037 to 0.469 N = 43 teams. —, not applicable. * P , .05; ** P , .01. significantly higher than that of those in the control condition, those in the sharing also boosts the accuracy and in the control group. We suggest 2 maternal gratitude condition efficiency of team diagnostics. possible explanations for this demonstrated enhanced diagnostic Receiving gratitude may generate the difference. First, the difference may and treatment outcomes. Although intensification of prosocial team stem from higher salience being the difference in outcomes (0.3 on the processes, such as workload and attributed to gratitude for some 5-point Likert scale) was statistically information sharing, for 2 main behaviors than for others. More significant and the proportion of reasons. First, when individuals are specifically, gratitude expressed for variance in outcomes explained thanked by others for a particular behaviors more central to the identity (33% and 41% of variance in action, they often experience stronger of those being thanked (eg, saving diagnostic and treatment outcomes, feelings of social worth and the a child’s life) may be more salient to respectively) reveals robust clinical need to give back, which, in turn, the targets of the gratitude expression significance, these effect sizes were motivates them to engage in further than those more distant (eg, somewhat smaller than those of such actions.35 This reciprocity participating in a training program) rudeness found in our earlier need not be direct.36 That is, an and thus may be more readily studies on these same outcomes.1,2 individual thanked for providing recognized and coded as expressions This is not surprising given the assistance may reciprocate by next of gratitude. Second, consistent with strong and consistent evidence providing feedback to a colleague or previous research on motivating hand that negative stimuli generate helping a different patient, with the hygiene,23 the difference may have more robust effects than do positive result being an upward spiral of something to do with the source, with ones.31 prosocial behavior within the team as gratitude expressed by patients or a whole.36 Second, when directed at their family members implicitly Moreover, our mediation analyses the team, expressions of gratitude deemed more genuine and/or salient provide us with insight as to the often signal to team members that than gratitude expressed by mechanisms underlying this effect, they have collectively made a positive colleagues or authority figures in the highlighting the critical role played by difference in other people’s lives, profession. Indeed, in the same way team information sharing. Although which, in turn, can bond members to that individuals at work often take gratitude had a robust and significant one another and intensify members’ the assistance provided by their impact on workload sharing, our sense of pride in and dedication to supervisors for granted and as part findings reveal that when included in the team.37 Studies reveal that team of the supervisory job,5 so might a model along with information identification is a robust predictor of medical team members take sharing, it is the latter (also individuals’ helping behaviors in expressions of gratitude from those influenced by gratitude) that affects – teams38 40 because team more senior to them for granted and both team diagnostic and procedural identification drives individuals to thus fail to recognize it as such. performance. Team member perceive their team’s collective information sharing has been shown norms, goals, and interests as their However, to the extent that gratitude to be critical not only for team own.41 is recognized (as in the case of the members to be able to anticipate each mother), gratitude expressions other’s responses to dynamic With the findings of our study, we do appear to be positively associated contingencies and allow for more not suggest that providers should with enhanced team processes and effective coordination of response but seek to elicit expressions of gratitude outcomes, explaining a large also for team learning and capability from patients and families. However, – proportion of the variance in such development.32 34 The findings they could suggest that providers outcomes. More specifically, we found presented here go beyond this, take time to interact more with their evidence that compared with teams suggesting that team information patients and families to find out their

Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 RISKIN et al experiences and emotional responses provide high-quality care, it does Fishman (Sheba Medical Center); and to care. This may improve the patient boost their collective ability to Dr Orna Flidel-Ramon (Kaplan experience and may also increase the do so. Accordingly, although the Medical Center). likelihood that teams will be exposed encouragement of gratitude and other We are also grateful to the to a performance-enhancing small, positive interpersonal participating teams from the NICUs of expression of gratitude. With our gestures may demand nothing short the following hospitals in Israel: Ziv fi ndings, we also suggest that, of culture change on the part of the Medical Center (Tzfat), Poriya following a practice increasingly medical community and those they Medical Center (), HaEmek fi adopted by airlines, medical systems serve, our ndings suggest that the Medical Center (), Bnai Zion fi might similarly leverage smartphone bene ts may well be worth the effort. Medical Center (Haifa), Rambam “ ” push technologies to allow patients Medical Center (Haifa), Carmel to more easily communicate their ACKNOWLEDGMENTS Medical Center (Haifa), Hillel Yaffe appreciation to the teams caring Medical Center (), Meir for them. We are grateful to the judges who Medical Center (Kfar Sava), Schneider evaluated the teams after each Children’s Hospital (Petach Tiqua), simulation and conducted the Sheba Medical Center (Tel HaShomer, CONCLUSIONS fl fi re exivity-based debrie ng: Dr Irit Ramat Gan), Lis Maternity Hospital Whereas expressions of gratitude Berger and Ms Shira Namimi (Lis (Tel Aviv), stemming from a senior colleague or Maternity Hospital, Sourasky Medical (), fi authority gure in medicine may not Center); Professor Dan Waisman and (), Shaare Zedek Medical be recognized as such, those Ms Lina Khoury (Carmel Medical Center (Jerusalem), Kaplan stemming from a patients or the Center); Dr Gil Talmon and Ms Dalal Medical Center (), Barzilai ’ patient s family members appear to Kasem-Jaber (HaEmek Medical Medical Center (), be both recognized and impactful, Center); Dr Ilan Segal (Barzilai and boosting critical team processes and, Medical Center); Ms Limor Partom (Beer Sheva). in turn, enhancing team diagnostic and Dr Adir Iofe (Bnai Zion Medical and treatment performance Center); Dr Bernard Barzilay and Ms We thank Ms Danya Ochana and Mr outcomes. Medical personnel may not Sophy Dombe (Assaf Haroefe Medical Peter Lawton for their kind assistance realize the tremendous effects that Center); Professor Smadar Even-Tov in the design of the study. We the expression of gratitude from Friedman (Hadassah Medical Center); appreciate the assistance of the family members may have on their Dr Arye Simmonds (Laniado professional team at MSR in the own functioning. After all, their Medical Center); Professor Michael preparation and operation of the professional credo obligates them to Schimmel and Ms Adina Gale simulation scenarios. make every effort to offer the best Dorembus (Shaare Zedek Medical care possible, regardless of (and even Center); Dr Huda Jubran and Ms despite) the response of family Fanny Timstut (Ruth Rappaport ABBREVIATIONS members. However, our findings Children’s Hospital, Rambam Medical ANOVA: analysis of variance indicate that although gratitude Center); Dr Raunak Saab (Poriya CI: confidence interval expressed by patients and their Medical Center); Dr Justin Richardson MSR: Israel Center for Medical families may not necessarily boost the and Dr Irina Maladin (Soroka Medical Simulation motivation of medical personnel to Center); Dr Ben Peleg and Ms Tanya

Address correspondence to Arieh Riskin, MD, MHA, Department of Neonatology, Bnai Zion Medical Center, 47 Golomb St, PO Box 4940, Haifa 31048, Israel. E-mail: arik. [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Dr Bamberger received support from the Jeremy Coller Research Foundation (grant 0612015501) and the Israel Science Foundation (research grant 1217/13) for the submitted work. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 4, April 2019 9 Expressions of Gratitude and Medical Team Performance Arieh Riskin, Peter Bamberger, Amir Erez, Kinneret Riskin-Guez, Yarden Riskin, Rina Sela, Trevor Foulk, Binyamin Cooper, Amitai Ziv, Liat Pessach-Gelblum and Ellen Bamberger Pediatrics originally published online March 7, 2019;

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 Expressions of Gratitude and Medical Team Performance Arieh Riskin, Peter Bamberger, Amir Erez, Kinneret Riskin-Guez, Yarden Riskin, Rina Sela, Trevor Foulk, Binyamin Cooper, Amitai Ziv, Liat Pessach-Gelblum and Ellen Bamberger Pediatrics originally published online March 7, 2019;

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