A recently published study has identified an association between coworker reports about unprofessional behaviour exhibited by surgeons and patients suffering complications of operations.(1) Cognitive Institute Senior Medical Educator Stephen Priestley discusses the findings.

A team from the Centre for Patient and Professional Advocacy at Vanderbilt University School of Medicine has identified that patients of surgeons with higher numbers of reports from coworkers about unprofessional behaviour are significantly more likely to experience complications during or after their operations.

The study’s findings contribute to an increasing understanding that complications of surgery are not only related to surgical technical skills but can also be attributed to non-technical skills. Complications commonly arise as a consequence of disruptions in teamwork and task performance that manifest when an individual displays unprofessional behaviours. These behaviours can be classified as aggressive behaviours, recognised as bullying, harassment and intimidation, or passive aggressive behaviours, such as persistent lateness, meeting avoidance and disdain for internal procedures.

Education programmes implemented within health service organisations such as the Promoting Professional Accountability programme – a partnership between Cognitive Institute and Vanderbilt University Centre for Patient and Professional Advocacy – have proven success in reducing unprofessional behaviours and promoting greater self-regulation.(2)

The ability to communicate clearly and respectfully and to be able to manage collaborative teams is essential to optimise patient outcomes amid the increased complexities of modern healthcare. This has been demonstrated through the successful implementation of the Promoting Professional Accountability programme by more than 240 organisations worldwide and post-implementation feedback has confirmed favourable clinical outcomes. Feedback identified staff did not often realise the impact certain behaviours had on patient safety, for example, poor hand hygiene and disregard for the safe surgery checklist. Research into the effectiveness of the programme reported 60% of physicians’ complaint scores improved after a level-one awareness intervention (3) and most physicians who received interventions responded with an 80% reduction in their complaint risk score (4).

While this new study from the Vanderbilt University School of Medicine focuses on the behaviours of surgeons, the premise of the findings highlight the importance of Cognitive Institute’s sector-wide work in contextualising unsafe behavior and equipping clinicians with the tools and mechanisms to address such behaviours. Enhanced communication skills, leadership capability and the ability to work effectively within and alongside teams promotes a strong culture of professional accountability and improved safe care for patients.

The data

The study used two large databases from two geographically diverse academic medical centres in the United States. The first database comprised electronic event reports of coworker concerns about professionalism entered into each hospital’s safety reporting system. The second database was the large National Surgical Quality Improvement Program (NSQIP) maintained by the American College of Surgeons that records comprehensive details of surgical operations and in hospital and post discharge complications up to 30 days from the date of the procedure.

Domains of unprofessional behaviours

The study included 13,653 patients undergoing operations performed by 202 surgeons across the two centres over 30 days. Surgical and medical complication rates were linked with the number of coworker reports of unprofessional behaviours that individual surgeons received in the preceding 36 months.

The research team analysed coworker reports of unprofessional behaviour using a validated coding algorithm and identified four domains of unprofessional behaviours. Reports recorded concerns about:

  • poor or unsafe care (eg failing to consistently perform hand hygiene)
  • clear and respectful communication (eg making derogatory comments about members of the operating room team)
  • integrity (eg not being truthful to staff or patients)
  • responsibility (eg refusing to sign or record orders in the patient record).

Surgical complications included site infections (superficial surgical site infection, deep surgical site infection, organ or space surgical site infection) and wound disruption. Medical complications included pulmonary conditions (pneumonia, reintubation or mechanical ventilation), renal conditions (renal insufficiency, acute renal failure), central nervous system or nervous system complications (stroke), cardiovascular conditions (cardiac arrest, acute myocardial infarction), thromboembolic conditions (pulmonary embolism, deep venous thrombosis) and infectious conditions (sepsis or septic shock, urinary tract infections).

The study found that patients whose surgeons had a higher number of coworker reports about unprofessional behaviours in the 36 months before the procedure were more likely to experience complications than patients who had no coworker reports. This difference remained after performing multivariable analyses controlling for patient, operative and surgeon characteristics.

Patients whose surgeons had one to three reports of unprofessional behaviour had an 18% higher estimated risk of experiencing complications. Those whose surgeons had four or more reports were at nearly 32% higher estimated risk compared to patients whose surgeons had no reports. There was no difference between groups in the percentage of patients who died, required a second operation or who were readmitted to the hospital within 30 days of their first operation.

The true impact of unprofessional behaviours

The study adds to the growing literature describing an association between unprofessional clinician behaviours and poorer patient outcomes. Its lead author, Dr William Cooper, Cornelius Vanderbilt Professor of Pediatrics and Health Policy at Vanderbilt University, was also the lead author of a previous study from 2017 (5) that found recording and analysing patient and family reports about rude and disrespectful behaviour can identify surgeons with higher rates of surgical site infections and other avoidable adverse outcomes.

Additional studies conducted in health care simulation labs have demonstrated the effect that rudeness can have on a team’s ability to perform. A study performed in simulated neonatal resuscitations revealed a significant worsening of both diagnostic and procedural performance in teams exposed to rudeness when compared to the performance of teams not exposed to rudeness. This was assessed by trained observers who were blinded to the rudeness intervention.(6) Rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance. Additionally, reduced information-sharing mediated the adverse effect of rudeness on diagnostic performance whilst reduced and help-seeking behaviours mediated the effect of rudeness on procedural performance.

Katz et al recently reported that exposure to incivility in the (simulated) operating room has a negative impact on anaesthesia trainee performance in several domains including technical skills, non-technical skills and a binary global performance metric. Overall, 91.2% of control group participants were rated as performing at their expected level, compared with only 63.6% of those exposed to incivility.(7)

While the majority of studies reported to date describe the impact of behaviours of clinicians engaged in performing procedures on patient outcomes, it is reasonable to assume that the same negative effects on team functioning are likely to be at play in other healthcare teams in our organisations with a potentially similar effect on patient outcomes.

Addressing unprofessional behaviours

Increased evidence of an association between unprofessional behaviours, detrimental effects on team functioning and worsened patient outcomes requires organisations to consider their culture. To ensure optimal patient outcomes organisations must consider strategies to address unprofessional behaviours, such as implementing culture change programmes and courses delivered by Cognitive Institute. In doing so, organisations will engage staff to behave in a manner that is aligned to the organisation’s values and the quality of care it wishes to provide to its patients and the community.

The Promoting Professional Accountability programme provides healthcare organisations with a sustainable, organisation-wide framework to achieve the highest levels of safety and reliability. It creates a systemic, positive environment where clinicians support each other to deliver safe care and address unprofessional behaviours that impact safety culture. The evidence-based programme provides the tools and procedure for defining critical safety and professionalism standards, and identifying, measuring and addressing behaviours that undermine them.

Read about how the Promoting Professional Accountability programme has assisted Ramsay Health Care to improve clinical outcomes and patient care – read the case study.


  1. Cooper WO, Spain DA, Guillamondegui O, Kelz RR, Domenico HJ, Hopkins J, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surgery. 2019.
  2. Webb LE, Dmochowski RR, Moore IN, Pichert JW, Catron TF, Troyer M, Martinez W, Cooper WO, Hickson GB. Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals. Jt Comm J Qual Patient Saf 2016; 42(4):149-64
  3. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med 2007; 82(11):1040-8
  4. Hickson GB, Cooper WA. Pursuing Professionalism (But not without an infrastructure). In: Byyny RL, Papadakis MA, Paauw DS, editors. Medical professionalism: best practices. Melo Park, California: Alpha Omega Alpha Honor Medical Society 2015:81-98.
  5. Cooper WO, Guillamondegui O, Hines OJ, Hultman CS, Kelz RR, Shen P, et al. Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications. JAMA Surgery. 2017;152(6):522-9.
  6. Riskin A, Erez A, Foulk TA, et al. The impact of rudeness on medical team performance: a randomized trial. Pediatrics. 2015;136:487-95.
  7. Katz D, Blasius K, Isaak R, Lipps J, Kushelev M, Goldberg A, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety. 2019:bmjqs-2019-009598.

    For information on the Promoting Professional Accountability programme, faculty, related workshops and courses contact us today.


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