The Cost of Disruptive Behavior in the Operating Room 

Hospitals and health systems continue to be under extraordinary financial pressure.  Following the unprecedented clinical and financial challenges of the COVID-19 pandemic, persistent labor shortages, high supply costs, and treatment of higher acuity patients remain constant pressures.  As the financial engine of the hospital, hospital leaders look to the operating room for opportunities to increase volume and optimize operations.  However, the operating room is not merely a revenue generator; it’s a dynamic ecosystem where every action, communication, and decision impacts patient outcomes. Beyond the sterile surfaces and bright lights, lies an intangible yet potent force – the culture of the operating room.

Process and performance metrics are easily tracked, reported on, and identified as opportunities for improvement. Yet do organizations recognize the significance of the elusive but powerful force of culture in the operating room? Culture is a critical component in achieving positive patient outcomes, providing quality care, recruitment, and retention of staff, as well as the economic success of the organization. Additionally, culture influences not only the atmosphere but also the efficiency, effectiveness, and safety of surgical procedures.

Team Dynamics

The OR is a collaborative environment where various healthcare professionals work together, including surgeons, nurses, anesthesiologists, and technicians.  Each member contributes a unique set of skills and expertise, forming a cohesive unit essential for navigating the complexities of surgery.  Healthcare professionals are constantly subjected to a myriad of stressors, coupled with the fast-paced nature of surgery and the inherent risks can impact performance and well-being.   

Effective communication is critical during surgical procedures to ensure that everyone is on the same page regarding patient care, surgical techniques, and equipment usage. Communication is crucial in the OR and a disruptive social interaction is not simply a relational stressor but can lead to negative events. The American Medical Association has defined disruptive behavior as personal conduct, whether verbal or physical, including (but not limited to) behaviors that interfere with the team’s ability to work with each other. (1)  Disruptive behavior in the OR encompasses a wide range of negative actions and attitudes that interfere with the smooth functioning of the surgical team and the delivery of patient care. This can include verbal outbursts, condescending remarks, refusal to cooperate, and non-verbal cues such as eye-rolling or sighing. Such behavior can be exhibited by any member of the surgical team, including surgeons, nurses, anesthesiologists, and support staff.

Situations that trigger of disruptive behaviors are often related to material resources, people, and management. For example, the lack of or wrong supplies, equipment failures, errors in the performance of team members, change of shift or unfamiliar team members, communication problems, or little to no compliance with procedures can result in disruptive behaviors.

Disruptive attitudes can decrease morale, inhibit communication, undermine teamwork and communication, and negatively impact the functioning of the team.  Persistent disruptive behavior takes a toll on the engagement and job satisfaction of OR staff, leading to increased rates of burnout, absenteeism, and staff turnover. High turnover rates further exacerbate efficiency challenges by necessitating frequent recruitment and onboarding of new staff members.

Recruitment and Retention

Recruitment and retention of perioperative nurses have been identified as the top challenge and priority for operating room leaders.  Perioperative leaders are likely to see high turnover rates and declining revenue if recruitment and retention are not a priority.  Creating the right working environment is critical to hiring and retaining high-quality perioperative nurses.

According to AORN’s perioperative education department, it can cost as much as $120,000 to train and prepare a new perioperative nurse. (2)  In addition, operating room nurse positions remain one of the most difficult to fill.  According to a 2019 AORN Salary Survey, 28% of respondents indicated they were likely or somewhat likely to quit within the next year and 17.5% intend to leave within the first year of starting a new job.  The top two reasons given were dissatisfaction with the work environment/culture and dissatisfaction with the supervisor/manager.

The American Nurses Association’s (ANA, 2015) position statement on incivility, bullying, and workplace violence clearly states the following: 

The nursing profession will no longer tolerate violence of any kind from any source. All RNs and employers in all settings, including practice, academia, and research, must collaborate to create a culture of respect that is free of incivility, bullying, and workplace violence.

Unfortunately, the culture in many operating rooms has remained “behind the red line” leading to fertile ground for incivility and bullying. The most commonly reported behaviors are verbal affront, nonverbal innuendo, undermining activities, withholding information, sabotage of an employee, inside fighting, scapegoating through another nurse, and backstabbing. (3)  According to Kaiser’s (2016) research on the relationship between leadership and nurse-to-nurse incivility, the rate of incivility is 10-15% higher in the nursing profession than in any other profession. Sadly, this behavior is primarily seen between senior nurses towards new nurses entering the OR. (4) This is reflected by the number of new nurses who resign during orientation or shortly after.  If perioperative leaders allow toxic cultures to persist, the OR will struggle to retain employees.  

Perioperative Leadership

At the heart of this complex environment lies the pivotal role of leadership. Effective leadership in the OR is not just about managing the daily operations of the department; it’s about fostering a culture of collaboration, communication, and accountability among team members. Conversely, poor leadership can have profound and far-reaching consequences that extend beyond the operating table, impacting patient safety, staff morale, and organizational performance.

One of the most significant impacts of poor leadership in the OR is the breakdown of communication channels among team members. Effective communication is essential for ensuring that everyone is aligned on the surgical plan, patient status, and any changes in procedure. When leadership fails to facilitate open and transparent communication, it can lead to misunderstandings, errors in judgment, and delays in decision-making, all of which compromise patient safety and clinical outcomes.

Poor leadership can erode trust and collaboration among members of the surgical team, creating a toxic work environment characterized by fear, resentment, and disengagement. When leaders fail to inspire confidence or demonstrate respect for their colleagues, it undermines the sense of teamwork and camaraderie that is essential for delivering high-quality patient care. In such environments, staff members may hesitate to speak up about concerns or share important information, fearing retribution or dismissal.

Perhaps the most alarming consequence is the increased risk of medical errors and adverse outcomes for patients. Leadership sets the tone for the entire surgical team, influencing attitudes, behaviors, and decision-making processes. When leaders fail to prioritize safety, accountability, or adherence to protocols, it creates an environment where errors are more likely to occur. Whether it’s overlooking critical information, failing to address concerns raised by team members, or succumbing to distractions, poor leadership can have dire consequences for patient safety.

At the organizational level, the impact of poor leadership in the OR is felt in terms of performance metrics, financial sustainability, and reputation. Healthcare institutions rely on efficient and effective surgical teams to deliver high-quality care and maintain their competitive edge. However, when leadership fails to cultivate a culture of excellence, innovation, and continuous improvement, it undermines the institution’s ability to achieve its strategic goals and fulfill its mission. Moreover, incidents of medical errors or adverse outcomes resulting from poor leadership can damage the institution’s reputation, leading to loss of patient trust and potential legal ramifications.

The impact of a negative culture and poor leadership in the operating room cannot be overstated. From communication breakdowns and erosion of trust to decreased morale and increased risk of medical errors can have profound and far-reaching consequences that extend beyond the operating table, impacting patient safety, staff morale, and organizational performance. Through recognition of the problem and implementing proactive measures to address it, healthcare institutions can cultivate a culture of collaboration, safety, and excellence in the OR, ultimately benefiting patients, staff, and the organization as a whole.

References:

1. American Medical Association; Report of the Council on Ethical and Judicial Affairs: physicians with disruptive behaviorhttps://www.ama-assn.org/resources/doc/code-medical-ethics/9045a.pdf (2002)
2. AACN Fact Sheet: Nursing shortage. American Association of Colleges of Nursing. https://www. aacnnursing.org/News-Information/Fact-Sheets/ Nursing-Shortage.
3. Workplace bullying in the OR: Results of a descriptive study;  Esther Chipps, Stephanie Stelmaschuk, Nancy M Albert, Linda Bernhard, Christopher Holloman; AORN Journal. 2013 Nov;98(5):479-93.
4. The relationship between leadership style and nurse-to-nurse incivility: turning the lens inward; Jennifer Kaiser; J Nurs Manag. 2017 Mar;25(2):110-118. doi: 10.1111/jonm.12447. Epub 2016 Nov 29