Eye signage in surgical theater areas has potential to decrease incivility

Australian researchers have successfully trialed a novel experiment to address offensive and rude comments in operating theaters by placing "eye" signage in surgical rooms.

The eye images, attached to the walls of an Adelaide orthopaedic hospital's operating theater without any explanation, had the desired effect of markedly reducing poor behavior among surgical teams.

Lead researcher University of South Australia Professor Cheri Ostroff attributed the result to a perception of being "watched," even though the eyes were not real.

The three-month experiment was undertaken to address a widespread culture of bullying and poor behavior in surgical theaters. So-called "incivility" is prevalent in many industries, including the health care sector and particularly in high-stress and high-pressure environments such as operating theaters. The findings have been published in PLOS ONE.

Prof Ostroff says rude and offensive remarks don't just affect staff morale, well-being, and productivity; they can also have a negative impact on patients.

"Teamwork is critical during surgery. When incivility contributes to poor communication in the operating theater, worse outcomes can result," Prof Ostroff says.

The consequences are far-reaching, leading to high staff turnover, low job satisfaction, a drop in productivity and less compliance with infection control and medication protocols.

Several interventions have been trialed internationally to address the poor behavior in surgical teams, including workshops and training sessions, but with limited success.

In the Adelaide study, an initial survey was sent out to 74 staff at a private hospital—including surgeons, trainees, nurses, anesthetists and technicians—asking people to report incidents of bad behavior in the operating theater. A month later, the eye signs were placed. Seven weeks later, a follow up survey was undertaken.

The impact was marked. Theater nurses in particular reported a marked drop in experiencing offensive and rude remarks.

Surgeon Dr. Nicholas Wallwork, who took part in the study, says the experiment shows that if people perceive they are being watched, they will change their behavior, even subconsciously.

"Rudeness and bullying occur in operating theaters because the stakes are high," he says. "There are at least six people working as a team in a confined space, under time pressures and with risks involved. A high-functioning stable team delivers better performance, but due to numerous factors this is sometimes difficult to achieve."

"Poor communication is a recognized problem in our industry, and it is not always from the top down, but across teams.

"The selection and training process is arduous—it takes 10 years to qualify as a surgeon—and it is a very competitive, intensive, and results-driven environment."

Complex leadership structures, where surgeons have direct clinical control of the staff during a shift, but are not line managers outside the operating theater, lead to conflict, Dr. Wallwork says.

"Unless we change this structure, which is leading to high burnout and frequent staff turnover, we will face a crisis in the industry."

Prof Ostroff says the study showed that poor behavior can be changed with simple interventions.

"Changing the workplace culture is important. In many health care settings, management are far removed from the day-to-day workplace stressors, creating a disconnect and lack of understanding."

The study identified four areas that need addressing:

• a need for senior management to be role models and emphasize respect in the workplace;
• appreciation and acknowledgment of employees' value;
• more open communication within teams and between staff and management;
• more clarity in respect to roles