Rudeness and Medical Team Performance Arieh Riskin, MD, MHA,a, b Amir Erez, PhD,c Trevor A. Foulk, BBA,c Kinneret S. Riskin-Geuz, BSc,d Amitai Ziv, MD, MHA,d, e Rina Sela, CCRN, MA,e Liat Pessach-Gelblum, MBA, e Peter A. Bamberger, PhDa

OBJECTIVES: Rudeness is routinely experienced by medical teams. We sought to explore the abstract impact of rudeness on medical teams’ performance and test interventions that might mitigate its negative consequences. METHODS: Thirty-nine NICU teams participated in a training workshop including simulations of acute care of term and preterm newborns. In each workshop, 2 teams were randomly assigned to either an exposure to rudeness (in which the comments of the patient’s mother included rude statements completely unrelated to the teams’ performance) or control (neutral comments) condition, and 2 additional teams were assigned to rudeness with either a preventative (cognitive bias modification [CBM]) or therapeutic (narrative) intervention. Simulation sessions were evaluated by 2 independent judges, blind to team exposure, who used structured questionnaires to assess team performance. RESULTS: Rudeness had adverse consequences not only on diagnostic and intervention parameters (mean therapeutic score 3.81 ± 0.36 vs 4.31 ± 0.35 in controls, P < .01), but also on team processes (such as information and workload sharing, helping and communication) central to patient care (mean teamwork score 4.04 ± 0.34 vs 4.43 ± 0.37, P < .05). CBM mitigated most of these adverse effects of rudeness, but the postexposure narrative intervention had no significant effect. CONCLUSIONS: Rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety. Interventions focusing on teaching medical professionals to implicitly avoid cognitive distraction such as CBM may offer a means to mitigate the adverse consequences of behaviors that, unfortunately, cannot be prevented.

a Coller School of Management, and dSackler School of Medicine, University of Tel Aviv, Tel Aviv, Israel; WHAT’S KNOWN ON THIS SUBJECT: Rudeness is b Neonatology, Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, routinely experienced by medical teams. Medical Haifa, Israel; cWarrington College of Business Administration, University of Florida, Gainesville, Florida; and eIsrael Center for Medical Simulation, Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel professionals exposed to rude behavior performed poorly on diagnostic and procedural tasks related Dr Riskin, conceptualized and designed the study, carried out the initial analyses, and drafted the to the medical treatment they provided. Reduced initial manuscript; Dr Erez conceptualized and designed the study, coordinated data collection, information sharing and helping mediated the carried out the initial analyses, and critically reviewed and revised the manuscript; Mr Foulk effects of rudeness on their performance. carried out the initial analyses and reviewed and revised the manuscript; Mrs Riskin-Geuz designed the data collection instruments, coordinated and supervised data collection, and WHAT THIS STUDY ADDS: Rudeness had adverse critically reviewed the manuscript; Dr Ziv designed the study, coordinated data collection, and consequences not only on therapeutic components critically reviewed the manuscript; Ms Sela designed the data collection instruments, coordinated of medical teams’ performance, but also on and supervised data collection, and critically reviewed the manuscript; Ms Pessach-Gelblum collaborative team processes essential for such designed the study, coordinated data collection, and critically reviewed the manuscript; performance. Cognitive bias modifi cation as a Dr Bamberger conceptualized and designed the study and drafted the initial manuscript; and preventative intervention mitigated most of these all authors approved the fi nal manuscript as submitted. negative consequences of rudeness. DOI: 10.1542/peds.2016-2305 Accepted for publication Nov 4, 2016 To cite: Riskin A, Erez A, Foulk TA, et al. Rudeness and Medical Team Performance. Pediatrics. 2017;139(2):e20162305

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 139 , number 2 , February 2017 :e 20162305 ARTICLE Rude and disrespectful behaviors, interactions as a risk factor for such team-level medical outcomes prevalent in all organizations, 1 iatrogenesis, 17 this study raised as diagnostic and procedural are increasingly widespread in 3 main questions that we seek to performance. high-intensity, service-oriented address in the current investigation. To address the third question, we organizations, such as hospitals and examined the potential mitigating health care facilities. 2 – 11 Doctors, First, although the preceding effects of 1 potential preventative nurses, and other health care findings suggest that collaborative intervention and 1 potential providers are regularly exposed to processes may be adversely affected treatment intervention. In terms rude behaviors from their superiors, by rudeness, we know little about of the former, framing rudeness peers, patients, and families of the team-level consequences of as a threatening stimulus eliciting patients. This is concerning because rudeness. Indeed, whereas laboratory appraisal and interpretation beyond the adverse effects such research using student participants (processes drawing cognitive behavior can have on their targets’ has consistently demonstrated the resources from the task at hand), well-being, 12 a growing body of adverse impact of rudeness on the we looked to interventions focused research indicates that rudeness performance of individual victims on cognitive bias modification can also have devastating effects and witnesses, 13 – 15 we are unaware (CBM) targeting threat-related on individual performance. For of research examining team-level interpretation biases. CBM example, studies have demonstrated effects. Accordingly, the first question interventions involve brief, that in comparison with controls, we address is the degree to which computerized cognitive training participants exposed to even mildly rudeness also affects team processes modules designed to alter threat- rude behavior (eg, insensitive and and, ultimately, team performance. oriented biases in interpretation unexpectedly disrespectful acts or Second, whereas the earlier study by promoting a more positive/ utterances) performed poorly on demonstrated the adverse effects benign rather than threat-based cognitive tasks, exhibited reduced of colleague-based rudeness, the interpretation of ambiguous creativity and flexibility, and were implications of rudeness stemming information or stimuli. 18 – 21 Similar, less helpful and prosocial. This effect from a patient or patient family preperformance cognitive training was observed regardless of whether member remain unknown. This is modules have been demonstrated they were the target of such behavior important because although medical to enhance attention control and or simply a witness. 13 –15 facilities may be able to control are in place in a wide variety of colleague-based rudeness, there is performance domains, including Building on such findings, in a recent little they can do to control patient or surgery and flight control.22 – 24 CBM study, we applied a simulation-based family rudeness. Hence, the second may have similar potential in this experimental design to examine the question we address is the degree to regard because it has been shown impact of colleague-based rudeness which findings regarding the impact to increase people’s resiliency to on a variety of individual-level of colleague-based rudeness are attention-diverting stressors by practitioner outcomes in a NICU generalizable to patient/family-based training them to shift their attention context, finding robust adverse rudeness. Finally, because rudeness away from threat. Accordingly, consequences with respect to can have such a devastating effect we posited that to the extent that accuracy of diagnosis and quality of on practitioner performance, we practitioners can learn to interpret care (ie, misspecification of medical questioned whether preventative interpersonal emotional expression orders and errors in fulfillment of and/or treatment interventions as less hostile, they and their medical orders).16 Moreover, we might mitigate these adverse effects. teammates should be less affected identified diminished information by such expressions and be better sharing and help seeking among the Accordingly, the first and second positioned to apply their cognitive NICU staff as key processes adversely aims of the current study were resources to the tasks at hand and affected by rudeness and mediating to see if we could replicate our provide enhanced clinical care. its impact on individual practitioner previous findings at the team level performance. 16 Overall, rudeness with rudeness stemming from The second, treatment intervention explained 43% of the variance in an alternative source (ie, patient was informed by research by practitioner performance; 20 points family). In this context, we examined Pennebaker on the treatment more than that accounted for by all the extent to which patient-based of victims of sexual abuse. 25 – 30 other commonly explored causes rudeness influenced such team- Pennebaker and others have of iatrogenesis, such as chronic level processes as information demonstrated that recovery sleep loss. 16 Aside from highlighting sharing, workload sharing, helping among such victims is facilitated the often overlooked role of social and communication, as well as by composing a narrative of the

Downloaded from www.aappublications.org/news by guest on September 30, 2021 2 RISKIN et al event. Underlying this approach Randomization teach debriefing skills, including is the notion that “constructing reflection, analysis, and planning. We Randomization was achieved by stories is a natural human process also reviewed with participants the using a system of randomly prepared that helps individuals understand section of the consent form indicating cards in sealed, nontransparent their experiences and themselves,” that they were free to withdraw envelopes containing the 4 condition thus facilitating “a sense of from the study at any time. Upon assignments. There were separate resolution, which results in less completing the final instruments envelopes for each simulation day. rumination and eventually allows at the end of the simulation day, At the start of each simulation day, disturbing experiences to subside all participants were debriefed. the research assistant drew the cards gradually from conscious thought.” 30 In this poststudy debriefing, we from the envelope and assigned Accordingly, we posited that by (1) again reviewed participants’ each of the preregistered teams writing a narrative about a rude right to withdraw from the study to 1 of the 4 conditions (control, event just experienced, practitioners as well as their right to withdraw rudeness, rudeness with narrative, would more efficiently process their personal data from the study; and rudeness with CBM) according the experience and thus be better (2) reminded participants that to the card pull for that day. On positioned to focus their attention on although the “patients” and “family those five simulation days on which their team and subsequent cases they members” that they interacted with a team scheduled to participate were asked to manage. in different scenarios were just failed to show up, the research manikins and actors, respectively, it assistant randomly excluded 1 of was perfectly normal to be disturbed the noncontrol condition cards from by some of these experiences; and METHODS the card draw to ensure that there (3) informed participants that was always a team in the control support was available for those Participants condition. feeling particularly disturbed by their experiences. None of the participants Thirty-nine NICU teams, each Ethical Considerations comprising 2 physicians and 2 withdrew their informed consent or nurses, were recruited from among Each team member underwent a requested that their data be withheld the various NICUs operating in prestudy, consenting process in or destroyed, and no one asked for Israel’s hospitals. Teams were offered which they signed an informed the psychological assistance that we the opportunity to join a full medical consent form (written per the offered to provide discretely. simulation training day in The Israel specifications of the institutional After reviewing the informed consent Medical Simulation Center at Sheba review boards of the first author’s forms, participants were briefed on Medical Center at Tel Hashomer. 31 university, and the medical center the reflexivity training exercise that The espoused purpose of the exercise with which Israel Center for Medical would occur at the conclusion of each was to train teams in the debriefing Simulation is affiliated). This of the simulations during the day. techniques described and examined form specified that the purpose by Vashdi et al as a means to of the study was to examine Scenarios facilitate team learning and enhance factors influencing medical team performance. 32 performance. As part of this process, Regardless of condition, the day participants were specifically told comprised 5 emergency scenarios in Procedure that in the course of the simulations, neonatal medicine: their performance would be recorded Neonate with severe jaundice Four teams were recruited for and observed by others, and that (pathologic hyperbilirubinemia) each simulation day. Two teams they would be required to interface because of glucose-6-phosphate- were randomly assigned to either with actors playing the role of their dehydrogenase deficiency. Because a rudeness (in which the scripted patients' family members. They intensive phototherapy did not comments of the infant’s mother were also told that rather than sufficiently reduce the bilirubin early in the day included a rude giving them feedback during the levels, double volume exchange statement completely unrelated to course of their simulation work, transfusion should be performed. the teams’ performance) or control observers would do so after each (neutral comments) condition, and simulation in the context of the Newborn in hypovolemic shock. The 2 additional teams were assigned to debriefing. We explained to them neonate was delivered via vacuum rudeness with either a preventative that these postsimulation sessions extraction and developed a rapidly (CBM) or therapeutic (narrative) would be used not only to provide expanding subgaleal hemorrhage intervention. performance feedback but also to with consumption coagulopathy.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 139 , number 2 , February 2017 3 Infant with severe respiratory discuss and develop a treatment plan were presented to the judges and distress after meconium for each clinical scenario. Specifically, discussed by them to ensure that aspiration syndrome. The neonate the team was required to identify the all had a common understanding of developed persistent pulmonary acute deterioration in the newborn’s their meaning and application. For hypertension, was intubated and condition and respond promptly each scenario, using a 5-point Likert received inhaled nitric oxide. His by providing the appropriate scale (1 = failed; 5 = excellent), judges respiratory status was further resuscitative treatments, while trying independently rated each team’s complicated by a pneumothorax to diagnose the underlying medical performance along items relating to necessitating insertion of a thorax condition. Based on conventional 9 parameters separated into 2 broad drain. protocol, the main actions required aspects of team performance: from the medical team were detailed Newborn with severe neonatal Medical and therapeutic for each scenario and distributed asphyxia with hypoxic ischemic performance—(1) Diagnostic to independent judges (senior encephalopathy. Total body performance (ie, time taken to neonatologists and veteran nurses) cooling, also referred to as diagnose, accuracy of diagnosis), to facilitate their monitoring and hypothermia treatment, is the (2) quality of therapy plan (ie, evaluation. The scenarios were state-of-the-art management of appropriateness of plan given designed such that a team’s failure this condition. diagnosis; plan accounts for unique to follow these specified actions constraints), (3) intervention (ie Imminent delivery of very premature would likely lead to further rapid procedural or skill performance), (23 weeks and 6 days gestation) deterioration and ultimately the and (4) overall general assessment extremely low birth weight infant infant’s demise within a short time. of medical therapy (eg, errors at the verge of viability. This The scenarios involved diagnostic made in diagnosis, therapy scenario required the team to and manual intervention skills and plan or execution; adequacy manage the initial delivery room required that members engage with of performance given unique resuscitation and stabilization. one another in making and executing constraints). 16 They then had to address the therapeutic decisions. Following neonate’s deterioration secondary each simulation, the team entered a Teamwork or relational cooperative to massive pulmonary hemorrhage separate room for a reflexivity-based aspects of performance within and severe bilateral grade IV debriefing. Prior to the start of the the team—(5) Information intraventricular hemorrhage. The reflexivity exercise, the judges were sharing, (6) workload sharing, (7) scenario required the team to asked to complete a questionnaire in helping among team members, manage family grieving as well as which they graded the participants’ (8) communication between team ethical dilemmas. performance. members, and (9) overall general assessment of teamwork. 16, 33 – 40 We arranged for the first scenario (incorporating the rudeness event) Measures Interventions to occur concomitantly across all Two independent NICU staff (1 4 conditions. The other scenarios Each NICU team was exposed to senior doctor and 1 experienced occurred in random order. comments or critiques by the infant’s nurse) blinded to the experimental parents, according to the control or In each scenario, the participants intervention observed each rudeness condition. These comments were told that the NICU manikin lying team’s performance in each of included neutral statements in in the incubator was their patient and the simulation scenarios from an the control condition or the same, that the patient’s vitals would appear adjacent control room with 1-way mildly rude statement (ie, “I knew on the monitors immediately at the mirrors and multiple video monitors we should have gone to a better start of the simulation. Additionally, allowing for close-up observation and hospital where they don’t practice the participants were provided with the monitoring of the patient’s vital Third World medicine!”) in all 3 of neonate’s medical history. They signs. Before serving in that capacity, the rudeness conditions (rudeness by were also informed that they might all judges underwent a daylong itself, CBM followed by rudeness, and encounter professional actors playing training program emphasizing rudeness followed by the narrative parents of their patient and would the monitoring and assessment of intervention). be asked to interact and respond the team (rather than individual to them as they would in real life. members) as the unit of analysis. Exposure to rude or neutral Additionally, participants were asked To enhance interrater reliability, as comments from the mother of the to work as a team and told that they part of this training, descriptors and infant occurred at the beginning of would receive 20 to 25 minutes to examples of indicative behaviors the first scenario of the day, which

Downloaded from www.aappublications.org/news by guest on September 30, 2021 4 RISKIN et al was the same for all groups (scenario trial began 100 to 400 milliseconds toward them, especially of the 1 of the infant with severe neonatal later. The order in which the various mother of the infant, as significantly jaundice). faces were displayed was randomly more polite (ie, less rude) in the determined. control condition (M = 4.75, Just before this first scenario, control SD = 0.45) than in the rude teams in the preventative, CBM During this game, the computer control condition (M = 3.75, SD = intervention 20 engaged in a program first determined the rudeness rudeness 0.77) (F = 16.31, P < .001). 20-minute computer game in participants threshold to threat (ie, 1,38 This effect remained consistent, which they looked at a series of angry faces) and then gave them although somewhat attenuated, morphing faces, 41 were asked to feedback designed to raise this through the end of the day (M = move a cursor to indicate whether threshold and as such “immunize” control 4.66, SD = 0.56 vs M = the emotion expressed was more of them from devoting substantial control rudeness 4.01, SD = 0.61, F = 9.26, anger or pleasure, and then received attention to minor threats. rudeness 1,38 P = .004), thus confirming that the immediate feedback on their choice. While teams in this condition were rudeness manipulation was effective. engaged in the CBM computer The Emotion Recognition Task of the Statistical Analysis CBM Intervention game, teams in the narrative intervention 28 – 30 worked on their All analyses were conducted using Stimuli for the task were generated first simulation and were exposed SPSS (version 23, IBM, Armonk, NY) using Morpheus Photo Morpher to the rudeness incident specified unless otherwise indicated. v3.16 (Morpheus Software, Grand earlier. Immediately after this A power analysis based on data from Rapids, MI). Four sequences of simulation, teams in this condition a previous study 16 and assuming morphed faces were generated were directed to a debriefing room a desired power of 80% with α based on the happy and angry and asked to write 1 or 2 paragraphs of .05 (2-sided test) indicated that pictures of 2 males and 2 females about how they thought the mother samples of at least 9 teams per taken from the NimStim set30. The of the infant felt when it seemed to condition would be required to faces were selected to represent her that the team was unsuccessful in capture moderate effects. Because both genders and different racial treating her newborn. each team’s performance in each origins (Caucasian, African American, In all, teams were randomly allocated of the scenarios was rated by 2 Hispanic, and Asian) and after pilot to 1 of 4 conditions: (1) control, (2) judges, we assessed reliability (the tests that demonstrated test–retest rudeness, (3) rudeness with the relative consistency among raters), validity for these morphed sequences CBM intervention, and (4) rudeness by calculating intraclass correlation in the emotion perception task. with the narrative intervention. coefficients (ICC ; R version 2.15.0, Each sequence consisted of 15 faces 1 Effects of rudeness exposure (vs The R Foundation for Statistical equally spaced on a continuum neutral control condition) and the Computing, Vienna, Austria). An between the happy and angry end moderating effect of the intervention ICC of 0.10 or higher indicated that points. Each face from each morphed 1 (CBM or narrative) were assessed the item could be averaged across sequence was presented 3 times, repeatedly throughout day. judges. 43 Comparisons of therapeutic for a total of 180 trials (4 sequences and teamwork performance scores × 15 faces × 3 repetitions). Faces Manipulation Check were done using multivariate ANOVA were displayed in a random order. (MANOVA). Comparisons of all Each trial began with a fixation cross The primacy effect of the rudeness variables included in therapeutic and (800–1200 milliseconds), followed manipulation and its possible teamwork performance scores in the by a color morphed face picture degradation over time was checked 4 conditions (ie control, rudeness, (90 mm in height and 70 mm in at 2 points during the simulation rudeness with narrative intervention width). The face was displayed for day, once at midday (after the third and rudeness with CBM intervention) 200 milliseconds and then masked scenario) and once at day’s end were analyzed using 1-way ANOVA. by a scrambled face display for (after the fifth and final scenario). Statistical significance was set at .05. 200 milliseconds. Then a question An analysis of variance (ANOVA) mark appeared on the screen and with the rudeness condition as the remained until a response was made. independent variable and perceived RESULTS Participants were instructed to press rudeness (assessed on the basis of a 1 of 2 designated buttons as fast as 4-item measure validated in previous To ensure that our randomization they could to indicate whether the research13, 14, 42 and with α = .93) as process of assigning teams to face was “angry” or “happy.” After the dependent variable indicated conditions was appropriate, we the participant’s response, the next that participants rated the attitude first tested whether the cumulative

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 139 , number 2 , February 2017 5 TABLE 1 Team Performance Scores—Control Versus Rudeness Control (n = 11) Rudeness (n = 10) FPη2 Mean SD Mean SD Diagnostic score 4.27 0.41 3.89 0.49 3.80 .07 0.17 Therapy plan 4.23 0.34 3.81 0.38 7.27* .01 0.28 Intervention score 4.38 0.36 3.75 0.37 15.43** .001 0.45 General therapeutic score 4.37 0.40 3.80 0.34 12.02** .003 0.39 Information sharing 4.41 0.42 4.08 0.36 3.65 .07 0.16 Workload sharing 4.40 0.44 3.93 0.35 7.06* .02 0.27 Helping 4.50 0.37 4.08 0.37 6.56* .02 0.26 Communication 4.42 0.38 4.03 0.45 4.64* .04 0.20 General teamwork score 4.43 0.39 4.06 0.34 5.62* .03 0.23 Midday manipulation check 4.75 0.45 3.98 0.37 19.21** <.001 — End day manipulation check 4.66 0.56 4.07 0.31 8.60** .009 — —, not applicable. * P < .05. ** P < .01. experience of the team’s members 5 indicators of teamwork score followed by rudeness” condition was distributed equally across the (ie, information sharing, workload versus control condition as the conditions. We conducted an ANOVA sharing, helping, communication, and factor, and medical/therapeutic with the conditions (eg, control, overall performance, with α = .96) performance and teamwork as the rudeness, rudeness with narrative to form scales. Next we conducted a dependent variables. The overall intervention, and rudeness with MANOVA with the rudeness versus model representing the influence CBM intervention) as the factor control condition as the factor of the CBM intervention on the and cumulative team experience and therapeutic and teamwork 2 dependent variables was not (eg, number of years in a NICU) scores as the dependent variables. significant (multivariate P = .61). as the dependent variable. The The overall model representing ANOVA results showed that after results showed that there were no the influence of rudeness on the 2 employing the CBM inoculation, significant differences between the dependent variables was significant rudeness did not affect the conditions (P = .26) indicating that (multivariate P < .05, η2 = 0.36). therapeutic score (P = .48), nor did it the randomization process had been ANOVA results showed that the affect the teamwork score (P = .47). successful. Controlling for cumulative rudeness condition affected both Table 2 reports mean comparison experience in all subsequent analyses the therapeutic score (P < .01, η2 = between the control and CBM groups did not significantly change any of 0.39; Mrudeness = 3.80, SDrudeness = for all performance measures. As the results. Therefore, we report 0.34, Mcontrol = 4.37, SDcontrol = 0.40) shown, the CBM intervention reduced the results without controlling for and the teamwork score (P < .05, the effects of rudeness on all the η2 cumulative experience. = 0.23; Mrudeness = 4.06, SDrudeness = team outcomes (eg, diagnostic score; 0.34, Mcontrol = 4.43, SDcontrol = 0.39). intervention score) and process (eg, Because each team’s performance in Table 1 reports mean comparison information sharing, communication) each of the scenarios was rated by 2 between the control and rudeness parameters. Thus, it seems that judges, we first assessed reliability groups for all performance measures. the CBM intervention succeeded in (the relative consistency among As shown, rudeness was associated “immunizing” participants from the raters) by calculating ICC1. The with diminished team performance effects of rudeness. resulting ICCs indicated moderate along all team outcomes (eg, Finally, we tested the effects of the to high interrater reliability, thus diagnostic score; intervention narrative intervention on the 2 supporting aggregation to the team score) and process (eg, information performance outcomes. Here again, level (data not shown but available sharing, communication) parameters, we first conducted a MANOVA from the first author). although these differences were only with the “rudeness followed by marginally significant (P < .10) in Next, we tested whether the rudeness narrative intervention” condition the case of diagnostic accuracy and manipulation harmed team’s versus control condition as the information sharing). performance. We first averaged the factor, and medical/ therapeutic 4 indicators of the therapeutic team Next, we tested the effects of the CBM performance and teamwork as the scores (ie, diagnostic, therapy plan, intervention on the performance dependent variables. The overall intervention, and overall therapeutic measures. We first conducted a model representing the influence of performance, with α = .97) and the MANOVA with the “CBM inoculation the narrative intervention on the 2

Downloaded from www.aappublications.org/news by guest on September 30, 2021 6 RISKIN et al TABLE 2 Team Performance Scores—Control Versus CBM intervention and process parameters Control (n = 11) CBM (n = 9) FPincluding team information and Mean SD Mean SD workload sharing. These findings not only replicate earlier findings 13, 14 Diagnostic score 4.27 0.41 4.26 0.56 0.00 .97 Therapy plan 4.23 0.34 4.14 0.71 0.15 .71 demonstrating the deleterious effects Intervention score 4.38 0.36 4.08 0.64 1.66 .21 of rudeness expressed by a senior General therapeutic score 4.37 0.40 4.19 0.66 0.52 .48 colleague on individual medical Information sharing 4.41 0.42 4.29 0.35 0.43 .52 performance16 but also extend Workload sharing 4.40 0.44 4.22 0.50 0.69 .42 them by demonstrating that similar Helping 4.50 0.37 4.26 0.34 2.16 .16 Communication 4.42 0.38 4.35 0.45 0.17 .68 effects are elicited by rudeness from General teamwork score 4.43 0.39 4.29 0.46 0.54 .47 other sources and are manifested Midday manipulation check 4.75 0.45 3.28 0.74 29.97** <.001 at the team level. Interestingly, End day manipulation check 4.66 0.56 3.72 0.68 11.64** .003 however, the effects of rudeness on ** P < .01. diagnosis and information sharing were only marginally significant. dependent variables was significant 3 shows that, similar to the rudeness Although we can only speculate as (multivariate P < .05, η2 = 0.31). without intervention condition, those to the relative weakness of these ANOVA results showed that the in the CBM intervention condition particular effects, one possibility is rudeness in the narrative condition viewed the mother in the rudeness that because these activities require affected both the therapeutic score manipulation scenario as more rude greater conscious effort, they may P η2 ( < .05, = 0.25; Mnarrative = 3.89, than those in the control condition be less subject to any threat-based P SDnarrative = 0.48, Mcontrol = 4.37, both at midday ( < .01) and at the redirection of cognitive resources P SDcontrol = 0.40) and the teamwork end of the day ( < .01). In contrast, away from the task. P η2 score ( < .05, = 0.22; Mnarrative = at midday those in the narrative 4.04, SDnarrative = 0.39, Mcontrol = 4.43, condition did perceive the mother to Additionally, we demonstrated that P SDcontrol = 0.39). Table 3 reports mean be more rude than controls ( < .05), a preventative or “immunization” comparison between the control and but by the end of the day, those in the CBM intervention, targeting negative narrative groups for all performance narrative condition did not view the interpretations of emotional displays measures. As shown, the narrative mother as more rude than controls and applied before the rudeness intervention did not reduce the (P = .09). incident, largely mitigated these effects of rudeness for any of the deleterious effects on team medical team outcomes (eg, diagnostic score; outcomes and processes, whereas a intervention score) and process (eg, DISCUSSION postincident, treatment intervention information sharing, communication) Our findings indicate that NICU teams based on victim’s composition of a parameters. Thus, the data indicate exposed to mild rudeness expressed narrative was largely ineffective in that the narrative intervention failed. by a patient’s mother resulted in doing so. Still, it should be noted that diminished team performance with although there was no statistically Examination of the manipulation respect to outcome parameters significant difference between the checks presented in Tables 1, 2, and relating to both diagnosis and performance scores of teams in the

TABLE 3 Team Performance Scores—Control Versus Narrative Control (n = 11) Narrative (n = 9) FP η2 Mean SD Mean SD Diagnostic score 4.27 0.41 3.88 0.52 3.64 .07 0.17 Therapy plan 4.23 0.34 3.81 0.57 4.30 .05 0.19 Intervention score 4.38 0.36 3.83 0.50 7.82* .01 0.30 General therapeutic score 4.37 0.40 3.89 0.48 5.85* .03 0.25 Information sharing 4.41 0.42 3.94 0.43 5.90* .03 0.25 Workload sharing 4.40 0.44 3.82 0.45 8.37* .01 0.32 Helping 4.50 0.37 4.17 0.22 5.66* .03 0.24 Communication 4.42 0.38 4.04 0.27 6.44* .02 0.26 General teamwork score 4.43 0.39 4.04 0.39 5.03* .04 0.22 Midday manipulation check 4.75 0.45 3.92 0.91 7.17* .01 — End day manipulation check 4.66 0.56 4.17 0.67 3.25 .09 — —, not applicable. * P < .05.

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 139 , number 2 , February 2017 7 CBM intervention and those of the participants’ positive reappraisal precisely in these situations, the teams in the control condition, the of her rude behavior, it failed to very collaborative processes that scores for the former were nominally help them overcome the cognitive generally enable teams to outperform lower, suggesting that for some disruption it caused. individuals may break down. To groups under certain conditions, the extent that rudeness impedes One possible explanation for this the CBM might not always be team helping and workload sharing, seemingly inconsistent finding is that entirely effective. Nevertheless, we teams may not be able to deliver the the cognitive processes involved in demonstrated that these mitigation heightened level of patient care that consciously reflecting on experienced effects of the CBM intervention were, practitioners have come to expect behavior and assessing its level of on average, sustained over the entire from them. Thus, we believe that our politeness (targeted by the narrative day. findings offer the first real evidence intervention and demanded by our of the impact that rudeness has on manipulation check for rudeness) Interestingly, examination of the the performance of medical teams are different from those involved in manipulation checks presented in and not just individuals working in more automatic determinations of Tables 1, 2, and 3 shows that similar teams. potential or actual threat (targeted to the rudeness without intervention by the CBM intervention). 44 It Second, these findings are important condition, those in the CBM is known that these 2 types of because, consistent with our earlier intervention condition viewed the cognitive processes do not always findings at the individual level, 16 mother in the rudeness manipulation operate in tandem. In the CBM task, they suggest that relatively benign scenario as more rude than those in the judgment is fast and crude in but negative human interactions the control condition. This suggests the sense that it requires a quick, could underlie many of the iatrogenic that the CBM intervention did not dichotomous response, whereas the incidents commonly occurring in distort participants’ views nor cause politeness rating score is based on a medical care settings. On one hand, it them to misperceive the mother’s more thoughtful judgment process is highly disturbing because, as noted, rude behavior. Instead, as designed, (answering a 4-item questionnaire such interactions are prevalent the CBM intervention “immunized” rated on a Likert scale). Interestingly, and, particularly in high-intensity, participants’ medical/therapeutic this reflective and thoughtful process life-and-death contexts, unlikely performance and teamwork by may be more similar to the one in to be preventable. On the other shifting their attention away from the narrative condition and hand, the finding that (as shown in the implicit threat posed by the thus might have been more Table 1) rudeness explains 39% of mother, thus likely preserving influenced by it. the variance in team-level general cognitive resources for the tasks at therapeutic outcomes (a figure hand. Results of these supplementary The findings of this study are remarkably similar to the effect size analyses indicated that the CBM significant in a number of respects: found in our earlier individual-level intervention operated not so first, our results reaffirmed how analysis 16) suggests that we may much by mitigating the appraisal rudeness can debilitate intervention have identified an important and of rudeness (indeed, those in this acuity, thus resulting in poorer potentially “treatable” iatrogenesis- condition viewed the perpetrator medical treatment and, particularly related risk factor. as more rude than those in other in the intensive care context studied, conditions), but by making team potentially catastrophic clinical Third, these findings are also members more resilient to the outcomes. Moreover, we also important in that they suggest this appraised rudeness; in particular, the demonstrated that these deleterious iatrogenesis-related risk factor intervention mitigated the degree effects of rudeness are not restricted may indeed be “treatable” on the to which such appraisals adversely to individuals as has been shown basis of “immunization” approaches affected their ability to engage in previously 16 but also to teams. structured around cognitive bias team processes (eg, workload and This is important because, based modification. Indeed, our finding information sharing) central to on the assumption that teams can that a 20-minute “computer game” timely and accurate diagnosis and often overcome and compensate for generated a sustained (daylong) error-free intervention. In contrast, individual performance limitations, mitigation effect suggests that by the end of the day, those in the medical work is increasingly being contextual rudeness might be more narrative condition did not view the structured around teams. 45 –48 Our amenable to intervention than are mother as more rude than controls. findings question the generalizability many other iatrogenesis-related These results suggest that although of this assumption in situations risk factors identified in previous writing about the experience from in which rudeness is prevalent research (eg, patient overcrowding, the mother’s perspective facilitated because they demonstrate that, physician workload, patient

Downloaded from www.aappublications.org/news by guest on September 30, 2021 8 RISKIN et al morbidity characteristics, length In conclusion, the findings presented Medical Center, Jerusalem; of hospitalization). Nevertheless, here suggest that the deleterious Dr Bernard Barzilay and Ms Sophy because daily CBM treatments are effects of rudeness on medical Dombe from Assaf Haroefe Medical unlikely to be feasible or efficacious, performance are no less severe on Center, Tzrifin, Rishon Lezion; Israel. additional research is needed to teams than they are on individuals We are also grateful to the estimate the robustness of the and that these effects are not participating teams from the neonatal exhibited mitigation effects over specific to any particular type of intensive care units of the following longer periods of time and source. Moreover, beyond its direct hospitals in Israel: Ziv Medical identify alternative CBM effect on cognitive functions and on Center, Tzfat; Haemek Medical approaches that might offer a performance of manual procedural Center, Afula; English Hospital, more sustained impact. skills, we showed that exposure Nazareth; Bnai Zion Medical Center, to rudeness debilitates the very Furthermore, although researchers Haifa; Rambam Medical Center, collaborative mechanisms, such as have hinted that contextual Haifa; Carmel Medical Center, Haifa; communication, workload sharing, adversity may result in heightened Hillel Yaffe Medical Center, Hadera; and helping, assumed to make rates of iatrogenesis by affecting Laniado Medical Center, Netanyah; team-based medical care more individual-level cognitive processing Meir Medical Center, Kfar Sava; effective and safe than that offered by and team-level collaborative Schneider Childrens’ Hospital, Petach individual care providers. However, processes,2, 16, 17, 45, 48 our findings Tiqua; Sheba Medical Center, Tel our findings also offer some basis identified and documented several Hashomer, Ramat Gan; Lis Maternity for optimism: although it may be of the collaborative processes most Hospital, Tel Aviv; Wolfsson Medical impossible to prevent patients and directly and adversely affected by Center, Holon; Haddasah Medical contextual rudeness. Indeed, an their families from being rude to Center, Jerusalem; Shhare Zedek understanding of the collaborative care providers, we may be able to Medical Center, Jerusalem; Kaplan mechanisms involved may facilitate “immunize” these same providers Medical Center, Rehovot; Barzilay the development of proactive and against the adverse implications of Medical Center, Ashkelon; Soroka reactive training and protocol such behavior on the performance Medical Center, Beer Sheva. of care providers and the teams to interventions designed either to We appreciate the assistance of the which they belong. strengthen these team processes or professional team at Israel Center for to compensate for them when they Medical Simulation in the preparation are weakened by the team’s exposure and operation of the simulation to rudeness. ACKNOWLEDGMENTS scenarios. We thank Professor Yair These study implications stand Bar-Haim and his PhD student in stark contrast to the policy We are grateful to the judges who Dr. Keren Maoz from the laboratory recommendations proposed by evaluated the teams after each for research on anxiety and trauma, leading health care think tanks simulation and conducted the School of Psychological Sciences with regard to patient safety, many reflexivity-based debriefing: Dr Omer and Sagol School of Neuroscience, of which emphasize the need to Globus and Ms Sarah Meir from Tel Aviv University, Israel for their enhance medical team engagement Sheba Medical Center, Tel Hashomer; insightful and helpful comments on and patient focus. 49 By highlighting Dr Ilan Segal from Barzilay Medical this manuscript. We thank Dr. Ellen the impact that adverse social Center, Ashkelon; Dr Arye Simmonds Bamberger from the department of contexts may have on team-level from Laniado Medical Center, Pediatrics and the Infection Control coordinative processes, our Netanyah; Ms Limor Partom from unit at Bnai Zion Medical Center for findings provide the foundation Bnai Zion Medical Center, Haifa; revising and professionally editing for a wide range of interventions Dr Irit Berger and Ms Anna Shtamler our manuscript. aimed at enhancing patient safety. from Lis Maternity Hospital, Our results suggest that instituting Sorasky Medical Center, Tel Aviv; protocols and procedures aimed at Dr Smadar Even-Tov Friedman, ABBREVIATIONS bolstering the defenses of medical Dr Ofra Peleg, Ms Deena Schwartz and ANOVA: analysis of variance teams to the cognitive distraction Ms Olga Gorodetzky from Haddassah CBM: cognitive bias modification and drain elicited by rudeness Medical Center, Jerusalem; Dr Dan ICC: intraclass correlation exposure can help mitigate the Waisman and Ms Lina Khoury from coefficient devastating consequences of these Carmel Medical Center, Haifa; MANOVA: multivariate analysis events, even when they cannot be Dr Reuven Bromiker and Ms Adina of variance prevented. Gale Dorembus from Shaare Zedek

Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 139 , number 2 , February 2017 9 Address correspondence to Arieh Riskin, MD, MHA, Department of Neonatology, Bnai-Zion Medical Center, 47 Golomb St, POB 4940, Haifa 31048, Israel. E-mail: arik. [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2017 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose. FUNDING: Professor Bamberger has support from the Israel Science Foundation research grant 1217/13, Israel Academy of Science and Humanities for this work. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

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Downloaded from www.aappublications.org/news by guest on September 30, 2021 Rudeness and Medical Team Performance Arieh Riskin, Amir Erez, Trevor A. Foulk, Kinneret S. Riskin-Geuz, Amitai Ziv, Rina Sela, Liat Pessach-Gelblum and Peter A. Bamberger Pediatrics 2017;139; DOI: 10.1542/peds.2016-2305 originally published online January 10, 2017;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2017 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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