������ϱ�

Avis Favaro

Behind the operating room doors are medical teams, working sometimes under extreme pressure to save lives. But studies show that over half of the nurses, attendants, physicians surveyed reported they’d been subject to uncivil behaviour, from rudeness to being ignored. Poor manners that Canadian surgeon, Carol-Anne Moulton, says she saw when she was an OR director.

Carol-Anne Moulton

Nurses saying that they would go home and cry because they felt like they were talked badly about. Or they would feel like they were totally disconnected and say, “I’ve been here for 10 years — why doesn’t this person know my name?”

Avis Favaro

And those studies show it can have a detrimental effect on staff morale and affect the safety of patients because it’s linked to higher rates of accidental injury in the OR, even higher rates of post-operative infection.

And so on this podcast, we will learn about Dr. Moulton’s new medical mission: improving civility in the OR. You’ll hear about how she and her team are starting with surgical caps, computerized team lineups and guessing games. You heard that. The first steps she hopes in changing the tone and the spirit of teamwork in the operating room.

Carol-Anne Moulton

My hope ultimately would be to create a movement and see kind of the impact that this might have across the world.

Avis Favaro

I’m Avis Favaro, and welcome to the Canadian Institute for ������ϱ� Information’s Podcast.

Every year, ������ϱ�reports on the state of Canada’s health workforce, and the stresses and shortages that the system faces. This episode looks at one doctor’s campaign to make operating rooms friendlier for staff and, ultimately, safer for patients.

If there’s any workplace in the world where team members are not fully visible, it’s the operating room. Nurses, doctors, attendants are gowned and masked when in the operating theatre, where they’re often referred to by their roles, not enough by their name.

Pam Hubley spent 30 years as an RN and vividly remembers feeling invisible.

Pam Hubley

Many surgeons would come to the floor to obviously care for their patients, to talk with the families, and it was 2 years before a surgeon actually called me by name.

Avis Favaro

A small act of civility, simply using her name, made all the difference.

Pam Hubley

And that moment when somebody acknowledged “Pam” — yeah, it was a wonderful moment because it was like you’re recognizing me as a person, you see me as a valuable contributor to the team.

Avis Favaro

Or like Dr. Carlos Ibarra, an anesthesiologist.

How often have you been called “Hey, you” in the operating room?

Carlos Ibarra

How often in the last 20 years or in the last week? The “Hey you” syndrome is quite widespread.

Avis Favaro

He tells us he’s worked very hard to develop connections with his colleagues at the University ������ϱ� Network in Toronto, where a new project you’ll soon hear about is underway.

But he also says that not all hospitals facilitate surgical civility. Add to that high staff turnover and stress… that makes good communication all the more difficult.

When someone doesn’t know your name, it leads to fear.

Carlos Ibarra

Yeah.

Avis Favaro

And does fear lead to mistakes?

Carlos Ibarra

Fear leads to mistakes. No doubt. Fear and tiredness. And that’s why it’s so important, and we have to be attentive to small details. The civility — and beyond civility — is a warm and friendly and fearless environment.

Avis Favaro

According to Dr. Carol-Anne Moulton, knowing people’s names has never been a thing in the surgical business.

Carol-Anne Moulton

We talk a lot about technical things here. We talk a lot about… we celebrate the surgeries. But the culture or the ways that we know each other is not something that we focus on.

Avis Favaro

She specializes in pancreatic and liver surgeries at the University ������ϱ� Network. She’s also a researcher, peering, as she puts it, behind the curtain of the operating room culture — an interest that started over a decade ago from her own experiences.

Take me to when you used to walk into the OR —

Carol-Anne Moulton

Yeah.

Avis Favaro

… and you might not know who’s on your team there.

Carol-Anne Moulton

Yeah.

Avis Favaro

How did you feel?

Carol-Anne Moulton

I think I felt a little bit… So when you say “How do you feel,” the thing is, it’s how you are when it’s normalized that you don’t know the team.

Avis Favaro

And yet you’re working on someone’s body.

Carol-Anne Moulton

So you know their roles — okay, that’s the circulating nurse, that’s the scrub nurse, that’s the anesthesiologist. And I have instances where that did make a difference for me. So I started appreciating that I should know. And why don’t I know? Like why is that a problem?

And then through our research, we actually started appreciating that there was a real thing about us not knowing each other’s names.

Avis Favaro

Did you end up leaving the OR feeling badly that maybe you didn’t know someone’s name and you would go “Hey, you”?

Carol-Anne Moulton

Yeah. I wouldn’t often say “you.” I would actually have my own ways of managing that. So I’d wait until they look at me and then… or say quietly to the resident or the trainee [whispering] “Who is that?” “What’s the anesthetist’s name?” So try to understand as a team. And we do that often: “Who’s that?” “What’s the scrub nurse’s name?”

Avis Favaro

That’s not the ideal.

Carol-Anne Moulton

It’s not ideal at all.

Avis Favaro

Yeah. Because you’re in an operating room, and —

Carol-Anne Moulton

Yeah. And sometimes you would just say loudly “Can you get me this?” Or I might talk to the scrub nurse who’s looking at me because I have her attention — “Can you get the stapler?” — rather than say to the circulating nurse who’s in the corner “Andrea, can you get me the stapler?”

Avis Favaro

Was there a moment where you started to feel bad and you said to yourself, I need to fix this?

Carol-Anne Moulton

We heard from many nurses — nurses saying that they would go home at the end of the day and cry because they felt like they were talked badly about what they did. Or they would feel like they were totally disconnected and say “I’ve been here for 10 years. Why doesn’t this person know my name?”

So they’re telling us as the researchers, and I’m thinking “Yeah, why don’t we know her name? That’s crazy.” And I know that I was guilty of it too because I was a surgeon in the same system.

Avis Favaro

Research suggests that inadequate communication is a primary cause of medical errors. Data from ������ϱ�shows that 1 in 17 patients admitted to hospital are harmed, with the largest group suffering post-surgical infections or bleeding after surgery.

Dr. Moulton has amassed a boatload of evidence on how medical teams interact, how surgeons lead the teams, and she is determined to improve the civility and the understanding of performance in the operating room theatre.

Was guilt the motivator to do the research?

Carol-Anne Moulton

It’s not guilt. It’s actually just a recognition that we could just be better, like we could be more well together and function better as a team. We wouldn’t talk to each other this way if we actually respected each other and knew each other. And we’re so busy that it’s not like the solution can’t always be “Well let’s have a party or let’s go for dinner.” It doesn’t work that way because there’s so many people that are involved.

I started understanding as the medical director that… and as someone who does the research in this area… how can we as a system take the responsibility off the individuals and fix it on a system level? So we don’t have to have individuals feeling bad that they don’t know people’s names. It shouldn’t be that way.

Avis Favaro

Her hospital, the University ������ϱ� Network in Toronto, agreed. In 2024, she became what appears to be the first surgeon in the world with this very title: Surgical Lead of Cognition and Culture. Simply put, she and her team are studying and implementing tools to reshape OR communications. You could call it medical etiquette, but it’s designed to be implemented by hospitals to improve civility and the flow of how people work in these high-stress environments.

You want happier surgeons, happier nurses, happier staff.

Carol-Anne Moulton

Fulfilled. People with meaning. To come to work and have meaning. Everybody wants that. A sense of belonging. We know that that’s important.

Avis Favaro

We are dealing with so many problems with shortages of staff.

Carol-Anne Moulton

Mm.

Avis Favaro

Is this the right time to be looking at civility?

Carol-Anne Moulton

I think it’s a perfect time, yes. Because I think that we have a lot of attrition, and largely because there’s a lot of stress and the shortage, backlog cases after COVID. That causes a lot of stress on all of us as the OR team, but particularly the surgeons. Like I have people not wanting to come to work or not wanting to be here because they are treated disrespectfully… is not helping.

So I think it is a good time. I think it’s a good time to value what we do and to… People should find meaning in their work, right?

Avis Favaro

We’re now inside the OR bay at UHN. Dr. Moulton and her team are in the first 6 months of their new mandate. It’s called the Transform OR Project. And they’re sharing 3 examples that they’ve started implementing.

Carol-Anne Moulton

So this is where everybody comes into the OR. So it’s kind of right where people see it. And a lot of the patients coming in and out kind of go past here.

Avis Favaro

The first is a large monitor high up on a wall inside the sliding OR bay doors. It features the faces of staff with their masks on and with the riddle “Who is this?”

In the next frame, the mask comes off. The man behind is Marcus George, Manager of Perioperative Support Services. And you see his face and learn personal details. We’ll post an example of it online on the ������ϱ�website.

And people know that you like the Leafs.

Marcus George

Unfortunately. That was when they were doing well. Now I’m not too sure.

Avis Favaro

Marcus told us this “Who is it” quiz eased this long-time pressure of remembering surgical team members.

Marcus George

There are so many people you have to work with, that we do work with. And a lot of times, it’s embarrassing when you don’t know people’s names. I meet you for the first time, and you introduce yourself, and on day 2 or 3, you can’t remember.

Avis Favaro

And Marcus said he too learned something new about his colleagues.

Marcus George

We had another attendant, David, and I worked with David for many years. I didn’t know that he had birds. So, yeah. And his favourite thing is to spend time with his bird, and I did not know that. And I worked with the guy for 15 years.

It also helped with patient safety, for example, or just keeping people calm in the operating rooms. Because the focus in the operating rooms, it’s so intense. You don’t need any other… any little issues that we have to take away from patient care.

The idea that she had that we all treat each other with respect, and the team aspect of it, it actually made the team more efficient.

Avis Favaro

Next, another initiative. Cloth surgical caps with the names of staff and their roles stitched on top.

Carol-Anne Moulton

It’s a visual reminder of somebody’s name. Like as I look up to the anesthesiologist, I need to sometimes get their attention and I don’t know their name. But now I can look up and actually see on the side of their cap their name.

Avis Favaro

Anesthesiologist Carlos Ibarra wears his cap proudly.

Can you think of any cases where it’s made a difference that you had your name on your cap so people can see it and that it sped up decision-making or care of a patient?

Carlos Ibarra

I feel it every day when people that I’m even unfamiliar with see the cap and call me “Hey, Carlos.” For me, it changes the mood immediately.

Avis Favaro

How many have you got with the names and how many do you have to go?

Carol-Anne Moulton

We have a lot to go. I think people need many hats because they have to wash their hats. I think the first initiative was 150 hats and now we’ve just ordered another 100 hats.

Avis Favaro

So you’re just starting to ramp up?

Carol-Anne Moulton

We’re just ramping up. But we also have now looked at getting our own machine so that… because there’s nurses in the OR that make hats and sell them for like cheap. But you can have like just this hat with masking tape on it with a name on it. That’s what some people do. We just have to value the idea that you have a name on a hat.

Avis Favaro

Dr. Moulton’s next tool is in the wings.

Carol-Anne Moulton

So these are the rooms. If you see on the whiteboard over there, on the far wall, you might see the surgeon and anesthetist nurses.

Avis Favaro

Yes.

It will replace the whiteboard that’s on the wall of most operating rooms. That’s where staff are supposed to print their names and their role in magic marker.

Carol-Anne Moulton

So that’s right now how we actually fill in who is in the room. It’s actually reliant on the nurses, usually the circulating nurse, to fill it in.

Avis Favaro

Is that good enough? So that’s the standard. Right?

Carol-Anne Moulton

It’s actually… if you look at that, there’s a room in here and there’s no names up there. So it’s not good enough. It’s not automatic. It’s relying on people to kind of remember to put it in. Often I would go in there and there would be yesterday’s team in there rather than it being updated. So it’s not a system initiative. It relies on educating people to do it, number 1.

Number 2, if I look at that, there’s usually 3 nurses in the room, and you have the names of 3 nurses. And I don’t know who they are. So I might know this one’s Jennifer. So I know that one’s Jennifer. But is this one Sally or is this one Andrea? Like I’m trying to guess, right?

Avis Favaro

Her team’s plan is to take the guesswork out of it and replace it with a computerized, automated staff listing system. It will look like those sports team lineups on TV before a game. 

Carol-Anne Moulton

So again, it’s just one more initiative that is a reminder of names. So it’s a system taking responsibility for individuals to know each other’s names. We already have all of the data in the computer system of who is in the room. And so we can actually have a library or storage of those names with the role and with a picture of who they are.

Avis Favaro

A photo.

Carol-Anne Moulton

A photo.

Avis Favaro

So that when they walk in, you can see —

Carol-Anne Moulton

I can see automatically who’s in the room, who the scrub nurse or the circulating nurse will be. You can have trainees up there as well. Whatever you decide to put up there, it’s all held in the computer.

Avis Favaro

We talked about that being like a football or a hockey lineup. Is anyone in the world doing that?

Carol-Anne Moulton

Not that I know of.

Avis Favaro

So this would be bringing it up into 2025?

Carol-Anne Moulton

Yeah, I think so.

Avis Favaro

Dr. Moulton and team have many other projects and studies underway, and some focus on where her mission all started with her own role as a surgeon, because her research is showing that the surgeons themselves can help set the mood for civility.

Carol-Anne Moulton

So you take on the surgeon identity in your training, and you have people that you looked up to who are these surgeons who are brave, and they do big cases, and they never seem to show these more vulnerable emotions. And so when you become a surgeon, you feel like you need to take on that. To be a good surgeon, you’re going to be that.

The problem is, that’s the front stage. It’s the impression that you manage to the outside world. As a surgeon, you recognize — I knew as a surgeon — there’s a backstage. It’s called the operating theatre for a reason. We are performers in the operating room. Like you can set a tone that’s not that respectful, and it kind of diminishes the role of some where they feel silenced. That’s on you as the surgeon to be aware of all of these things, which is sometimes hard.

Avis Favaro

It’s almost like you’re lifting the cloak of invisibility.

Carol-Anne Moulton

Totally. So my talk is Beyond Cognition: Peeking Behind the Curtain. So this is what we’re doing. We’re talking about things that just don’t get talked about but are really important.

Avis Favaro

Remember Pam Hubley, who rejoiced when a surgeon first called her by name? She’s now a VP at the hospital and senses these first initiatives are starting to change the culture for surgical teams.

Pam Hubley

What we’re saying today is we actually want everybody speaking up, feeling proud of what they’re doing, having conversation. We need to really improve our communication.

Avis Favaro

For what end?

Pam Hubley

Really for patient safety, and then secondarily for team cohesion, team understanding, team fulfillment.

Avis Favaro

Are you seeing measures that are starting to take place having an effect on patient safety? And how do you know that?

Pam Hubley

Yes. I think that that is… we are seeing a difference in the culture because we are intentionally inviting people to speak up. So it’s more collegial, I would say, and that’s really important. It does keep patients safe. It does improve the quality of care because it improves the communication.

Avis Favaro

And it is for Dr. Moulton an encouraging sign that hospitals can help build in systems to promote effective collaboration and teamwork.

What’s your hope?

Carol-Anne Moulton

My hope ultimately would be to create a movement and see kind of the impact that this might have across the world. I just think it’s possible, and I think that — I’m not good with social media or… this is probably one of the reasons why we need people like you — but I think that most people — and I’m talking about this like all over the world — this is an issue all over the world.

Avis Favaro

Operating rooms aren’t factories. They’re living, breathing teams working to save lives. And so the quality of their working lives do matter in helping retain staff and improve job satisfaction. Watch for data from Dr. Moulton’s team in the months ahead.

Thank you so much for listening. Remember that you can find much more data on the Canadian health care system on the website at C-I-H-I dot C-A. And please subscribe to the Canadian ������ϱ� Information Podcast wherever you get your shows.

I’m Avis Favaro. Talk to you next time.