“Disruptive behavior” in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams

Autoři: Sandra Keller aff001;  Franziska Tschan aff001;  Norbert K. Semmer aff003;  Eliane Timm-Holzer aff001;  Jasmin Zimmermann aff001;  Daniel Candinas aff004;  Nicolas Demartines aff005;  Martin Hübner aff005;  Guido Beldi aff004
Působiště autorů: Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland aff001;  Virginia Tech, Blacksburg, VA, United States of America aff002;  Institute of Work Psychology, University of Bern, Bern, Switzerland aff003;  Department of Visceral Surgery and Medicine, University Hospital of Bern, Bern, Switzerland aff004;  Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland aff005
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: 10.1371/journal.pone.0226437



Tense communication and disruptive behaviors during surgery have often been attributed to surgeons’ personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.

Methods and findings

The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.


Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

Klíčová slova:

Anxiety – Digestive system procedures – Emotions – Personality – Professions – Surgeons – Surgical and invasive medical procedures – Technicians


1. Jones LK, Jennings BM, Higgins MK, de Waal FBM (2018) Ethological observations of social behavior in the operating room. Proc Natl Acad Sci U S A 115: 7575–7580. doi: 10.1073/pnas.1716883115 29967170

2. Rosenstein AH, O'Daniel M (2006) Impact and implications of disruptive behavior in the perioperative arena. Journal of the American College of Surgeons 203: 96–105. doi: 10.1016/j.jamcollsurg.2006.03.027 16798492

3. Halim UA, Riding DM (2018) Systematic review of the prevalence, impact and mitigating strategies for bullying, undermining behaviour and harassment in the surgical workplace. Br J Surg 105: 1390–1397. doi: 10.1002/bjs.10926 30007001

4. Lingard L, Reznick R, Espin S, Regehr G, DeVito I (2002) Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med 77: 232–237. doi: 10.1097/00001888-200203000-00013 11891163

5. Espin SL, Lingard LA (2001) Time as a Catalyst for Tension in Nurse-Surgeon Communication. AORN Journal 74: 672–682. doi: 10.1016/s0001-2092(06)61766-3 11725445

6. Simpson KR (2007) Disruptive clinician behavior. MCN: The American Journal of Maternal/Child Nursing 32: 64.

7. Villafranca A, Hamlin C, Enns S, Jacobsohn E (2017) Disruptive behaviour in the perioperative setting: a contemporary review. Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie 64: 128–140. doi: 10.1007/s12630-016-0784-x 27900669

8. Andersson LM, Pearson CM (1999) Tit for tat? The spiraling effect of incivility in the workplace. Academy of Management Review 24: 452–471.

9. Leape LL, Shore MF, Dienstag JL, Mayer RJ, Edgman-Levitan S, et al. (2012) Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med 87: 845–852. doi: 10.1097/ACM.0b013e318258338d 22622217

10. Gittell JH (2015) Relational coordination. In: Flood PC, Freeney Y, editors. Organizational behavior (Wiley Encyclopedia of Management, ed by Cooper C, 3rd ed, vol 11). London: Wiley. pp. 425–430.

11. Smith LM, Andrusyszyn MA, Spence Laschinger HK (2010) Effects of workplace incivility and empowerment on newly-graduated nurses’ organizational commitment. Journal of Nursing Management 18: 1004–1015. doi: 10.1111/j.1365-2834.2010.01165.x 21073572

12. Rosenstein AH, O’Daniel M (2006) Impact and implications of disruptive behavior in the perioperative arena. Journal of the American College of Surgeons 203: 96–105. doi: 10.1016/j.jamcollsurg.2006.03.027 16798492

13. Jones LK, Jennings BM, Goelz RM, Haythorn KW, Zivot JB, et al. (2016) An Ethogram to Quantify Operating Room Behavior. Ann Behav Med 50: 487–496. doi: 10.1007/s12160-016-9773-0 26813263

14. Chrouser KL, Partin MR (2019) Intraoperative Disruptive Behavior: The Medical Student's Perspective. J Surg Educ.

15. Cochran A, Elder WB (2014) A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg 219: 390–398. doi: 10.1016/j.jamcollsurg.2014.05.011 25067803

16. Rosenstein AH, Naylor B (2011) Incidence and Impact of Physician and Nurse Disruptive Behaviors in the Emergency Department. J Emerg Med.

17. Pattani R, Ginsburg S, Johnson AM, Moore JE, Jassemi S, et al. (2018) Organizational factors contributing to incivility at an academic medical center and systems-based solutions: a qualitative study. Academic Medicine 93: 1569. doi: 10.1097/ACM.0000000000002310 29901655

18. Dixon-Woods M, Campbell A, Martin G, Willars J, Tarrant C, et al. (2019) Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Acad Med 94: 579–585. doi: 10.1097/ACM.0000000000002447 30211753

19. Jones LK, Jennings BM, Higgins MK, de Waal FBM (2018) Ethological observations of social behavior in the operating room. Proceedings of the National Academy of Sciences 115: 7575–7580.

20. Coe R, Gould D (2008) Disagreement and aggression in the operating theatre. J Adv Nurs 61: 609–618. doi: 10.1111/j.1365-2648.2007.04544.x 18302602

21. Patelarou A, Laliotis A, Sifaki Pistola D, Marinaki S, Androulaki Z, et al. (2014) Do we really collaborate effectively in the operating theatre? A cross- sectional study in two hospitals in Greece. International Journal of Advanced Nursing Studies 3.

22. Riley R, Manias E (2006) Governing time in operating rooms. Journal of clinical nursing 15: 546–553. doi: 10.1111/j.1365-2702.2006.01362.x 16629963

23. Nurok M, Sundt TM 3rd, Frankel A (2011) Teamwork and communication in the operating room: relationship to discrete outcomes and research challenges. Anesthesiol Clin 29: 1–11. doi: 10.1016/j.anclin.2010.11.012 21295749

24. Weiss HM, Cropanzano R (1996) Affective events theory: A theoretical discussion of the structure, causes and consequences of affective experiences at work.

25. Cochran A, Elder WB (2015) Effects of disruptive surgeon behavior in the operating room. The American Journal of Surgery 209: 65–70. doi: 10.1016/j.amjsurg.2014.09.017 25454961

26. Riskin A, Bamberger P, Erez A, Foulk T, Cooper B, et al. (2019) Incivility and Patient Safety: A Longitudinal Study of Rudeness, Protocol Compliance, and Adverse Events. The Joint Commission Journal on Quality and Patient Safety 45: 358–367. doi: 10.1016/j.jcjq.2019.02.002 30904328

27. Higgins BL, Macintosh J (2010) Operating room nurses' perceptions of the effects of physician‐perpetrated abuse. International Nursing Review 57: 321–327. doi: 10.1111/j.1466-7657.2009.00767.x 20796061

28. Riskin A, Erez A, Foulk TA, Riskin-Geuz KS, Ziv A, et al. (2017) Rudeness and Medical Team Performance. Pediatrics 139.

29. Salazar MJB, Minkoff H, Bayya J, Gillett B, Onoriode H, et al. (2014) Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. Journal of the American College of Surgeons 219: 1001–1007. doi: 10.1016/j.jamcollsurg.2014.07.933 25256368

30. Hood AC, Bachrach DG, Zivnuska S, Bendoly E (2015) Mediating effects of psychological safety in the relationship between team affectivity and transactive memory systems. Journal of Organizational Behavior: n/a-n/a.

31. Håkonsson DD, Mitkidis P, Wallot S (2017) Team Emotions and Team Learning. In: Argote L, Levine JM, editors. The Oxford Handbook of Group and Organizational Learning.

32. Greer LL, Jehn KA (2007) The pivotal role of negative affect in understanding the effects of process conflict on group performance. In: Mannix EA, Neal MA, Anderson CP, editors. Affect and Groups: Emerald Group Publishing Limited. pp. 21–43.

33. Fischer AH, Manstead ASR, Zaalberg R (2011) Social influences on the emotion process. European Review of Social Psychology 14: 171–201.

34. de Wit FRC, Greer LL, Jehn KA (2012) The Paradox of Intragroup Conflict: A meta-analysis. Journal of Applied Psychology 97: 360–390. doi: 10.1037/a0024844 21842974

35. De Dreu CKW, Weingart LR (2003) Task versus relationship conflict, team performance, and team member satisfaction: A meta-analysis. Journal of Applied Psychology 88: 741–749. doi: 10.1037/0021-9010.88.4.741 12940412

36. Elfenbein HA (2007) 7 Emotion in Organizations. The Academy of Management Annals 1: 315–386.

37. Seelandt JC, Tschan F, Keller S, Beldi G, Jenni N, et al. (2014) Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. BMJ Qual Saf 23: 918–929. doi: 10.1136/bmjqs-2014-002860 25013008

38. Tschan F, Holzer E, Semmer NK, Keller S, Zimmermann J, et al. (2016) Adjustable Field Notes—A 5$ iPad application to observe team interactions 10th International Meeting for Behavioral Science in Surgery & Acute Care Settings, November 11th-12th, 2016. Aberdeen

39. Lingard L, Garwood S, Poenaru D (2004) Tensions influencing operating room team function: does institutional context make a difference? Medical Education 38: 691–699. doi: 10.1111/j.1365-2929.2004.01844.x 15200393

40. Krippendorff K (2004) Content Analysis. an introduction to its methodology. Thousand Oaks, CA: Sage

41. Gardezi F, Lingard L, Espin S, Whyte S, Orser B, et al. (2009) Silence, power and communication in the operating room. Journal of Advanced Nursing 65: 1390–1399.

42. Jehn KA, Mannix EA (2001) The dynamic nature of conflict: A longitudinal study of intragroup conflict and group performance. Academy of Management Journal 44: 238–251.

43. Islam G, Zyphur MJ (2005) Power, Voice, and Hierarchy: Exploring the Antecedents of Speaking Up in Groups. Group Dynamics: Theory, Research, and Practice 9: 93–103.

44. Pearson CM, Porath CL (2005) On the nature, consequences and remedies of workplace incivility: No time for “nice”? Think again. Academy of Management Perspectives 19: 7–18.

45. Delvaux E, Vanbeselaere N, Mesquita B (2015) Dynamic Interplay Between Norms and Experiences of Anger and Gratitude in Groups. Small Group Research 46: 300–323.

46. Jones EE, Harris VA (1967) The attribution of attitudes. Journal of Experimental Social Psychology 3: 1–24.

47. Hewstone M (1990) The ‘ultimate attribution error’? A review of the literature on intergroup causal attribution. European Journal of Social Psychology 20: 311–335.

48. Stewart TL, Latu IM, Kawakami K, Myers AC (2010) Consider the situation: Reducing automatic stereotyping through Situational Attribution Training. Journal of Experimental Social Psychology 46: 221–225.

49. Lingard L, Regehr G, Espin S, Devito I, Whyte S, et al. (2005) Perceptions of operating room tension across professions: building generalizable evidence and educational resources. Acad Med 80: S75–79. doi: 10.1097/00001888-200510001-00021 16199464

50. Mrkonjic L, Grondin SC (2011) Introduction to concepts in leadership for the surgeon. Thorac Surg Clin 21: 323–331. doi: 10.1016/j.thorsurg.2011.04.001 21762855

51. Parker SH, Yule S, Flin R, McKinley A (2011) Surgeons' leadership in the operating room: an observational study. American Journal Of Surgery 204: 347–354. doi: 10.1016/j.amjsurg.2011.03.009 22178486

52. Mitchell L, Flin R, Yule S, Mitchell J, Coutts K, et al. (2011) Thinking ahead of the surgeon. An interview study to identify scrub nurses' non-technical skills. International Journal of Nursing Studies 48: 818–828. doi: 10.1016/j.ijnurstu.2010.11.005 21190685

53. Joseph A, Khoshkenar A, Taaffe KM, Catchpole K, Machry H, et al. (2018) Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Qual Saf.

54. Rogers DA, Lingard L, Boehler ML, Espin S, Schindler N, et al. (2013) Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. American Journal Of Surgery 206: 428–432. doi: 10.1016/j.amjsurg.2013.03.002 23827514

55. Tørring B, Gittell JH, Laursen M, Rasmussen BS, Sørensen EE (2019) Communication and relationship dynamics in surgical teams in the operating room: an ethnographic study. BMC Health Services Research 19: 528. doi: 10.1186/s12913-019-4362-0 31358000

56. Parker SE, Laviana AA, Wadhera RK, Wiegmann DA, Sundt TM, 3rd (2010) Development and evaluation of an observational tool for assessing surgical flow disruptions and their impact on surgical performance. World J Surg 34: 353–361. doi: 10.1007/s00268-009-0312-z 20012288

57. Knight AP, Eisenkraft N (2015) Positive is usually good, negative is not always bad: The effects of group affect on social integration and task performance. Journal of Applied Psychology 100: 1214–1227. doi: 10.1037/apl0000006 25495091

58. Cole MS, Walter F, Bruch H (2008) Affective mechanisms linking dysfunctional behavior to performance in work teams: A moderated mediation study. Journal of Applied Psychology 93: 945–958. doi: 10.1037/0021-9010.93.5.945 18808218

59. Gittell JH, Seidner R, Wimbush J (2010) A relational model of how high-performance work systems work. Organization Science 21: 490–506.

60. Sun R, Marshall DC, Sykes MC, Maruthappu M, Shalhoub J (2018) The impact of improving teamwork on patient outcomes in surgery: A systematic review. Int J Surg 53: 171–177. doi: 10.1016/j.ijsu.2018.03.044 29578095

61. Tschan F, Seelandt J, Keller S, Semmer NK, Kurmann A, et al. (2015) Impact of case-relevant and case-irrelevant communication within the surgical team on surgical site infection. British Journal of Surgery.

62. Müller P, Tschan F, Keller S, Seelandt J, Beldi G, et al. (2018) Assessing perceptions of teamwork quality among perioperative team members AORN 180.

63. Janss R, Rispens S, Segers M, Jehn KA (2012) What is happening under the surface? Power, conflict and the performance of medical teams. Medical Education 46: 838–849. doi: 10.1111/j.1365-2923.2012.04322.x 22891905

64. Rogers DA, Lingard L, Boehler ML, Espin S, Mellinger JD, et al. (2013) Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors. American Journal Of Surgery 205: 125–130. doi: 10.1016/j.amjsurg.2012.05.027 23141805

65. Davidson K, MacGregor MW, Stuhr J, Gidron Y (1999) Increasing constructive anger verbal behavior decreases resting blood pressure: A secondary analysis of a randomized controlled hostility intervention. International Journal of Behavioral Medicine 6: 268–278. doi: 10.1207/s15327558ijbm0603_5 16250680

66. Greer LL, Saygi O, Aaldering H, de Dreu CK (2012) Conflict in medical teams: opportunity or danger? Medical Education 46: 935–942. doi: 10.1111/j.1365-2923.2012.04321.x 22989127

67. Henrickson Parker S, Schmutz JB, Manser T (2018) Training needs for adaptive coordination: Utilizing task analysis to identify coordination requirements in three different clinical settings. Group & Organization Management 43: 504–527.

68. Salas E, DiazGranados D, Weaver SJ, King H (2008) Does team training work? Principles for health care. Academic Emergency Medicine 15: 1002–1009. doi: 10.1111/j.1553-2712.2008.00254.x 18828828

69. Burke CS, Salas E, Wilson-Donnelly K, Priest H (2004) How to turn a team of experts into an expert medical team: guidance from the aviation and military communities. Quality and Safety in Health Care 13: i96–i104. doi: 10.1136/qshc.2004.009829 15465963

70. Schmutz JB, Eppich WJ (2017) Promoting learning and patient care through shared reflection: A conceptual framework for team reflexivity in health care. Academic Medicine 92: 1555–1563. doi: 10.1097/ACM.0000000000001688 28445215

71. Kündig P, Tschan F, Semmer NK, Morgenthaler C, Zimmermann J, et al. (2019) More than experience: a post-task reflection intervention among team members enhances performance in student teams confronted with a simulated resuscitation task—a prospective randomised trial. BMJ Simulation and Technology Enhanced Learning: bmjstel-2018-000395.

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2019 Číslo 12