Bad behaviour in the operating theatre improves when surgical staff are being “watched” – even by eyes printed on a poster, an Adelaide study suggests.

Surveys administered three months apart in a private hospital showed that signage of eyes with no explanation significantly decreased reported incivility in surgical teams such as rudeness, derision, insulting remarks and humiliation.

Writing in PLOS One [link here], the researchers proposed the simple intervention was enough to trigger automatic cognitive mechanisms to regulate behaviour.

“Because human cooperative behaviour is purported to be largely regulated by social sanctions, being observed can unconsciously prompt people to modify their behaviour accordingly,” wrote the University of South Australia researchers.

“This effect can be evoked with images of eyes that are only minimally similar to actual observer’s eyes. Evoking perceptions of being observed, such as through a picture of eyes on the wall, has been shown to reduce crime and littering, and to increase honesty, voting behaviour, and charitable giving.”

The 74 participants in the study were perioperative surgical team members, including surgeons, anaesthetists, assistants, ancillary specialists, scrub nurses, admission nurses and recovery nurses, at an orthopaedic hospital in Adelaide.

They were asked to fill out brief surveys assessing incivility, team dynamics, burnout, stress, and job attitudes before and after the placement of 16 eye signs through surgical team areas, including two in each of the five operating theatres.

A three month break between surveys aimed to avoid capturing an immediate ‘one-off’ effect of the posters, while minimising any effects of staff turnover.

Findings revealed that 93% participants experienced or observed at least one event of incivility at baseline, which decreased to 86% after poster placement.

On average, they reported experiencing or observing incivility a mean two times per week and four different types of incivility events within a month, which significantly correlated with greater burnout, stress and poorer job attitudes.

“Using mediation analytical techniques, we were able to show that the relationship between incivility and well-being in surgical teams occurs largely through its impact on team dynamics, i.e., constructive communication in a psychologically safe manner,” the researchers said.

“This is important because communication and teamwork are critical elements for safety and optimising care and a substantial percentage of preventable adverse effects in surgery can be traced to communication failures.

“Of note, there can be significantly different perceptions of communication among surgical team members, with surgeons tending to report better communication compared to those in other roles. Likewise, growing evidence highlights differences between male and female surgeons in interpersonal communication and conflict.”

They conceded, however, while effective in their study, it was unlikely that the effect of an intervention such as ‘eye’ signs would be long-lasting and should instead be viewed as one component of a larger program to address and reduce incivility.