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Cognitive load and the safe delivery of healthcare

By Julinda Schroeder - 22nd Oct 2023

cognitive load
Pictured L-to-R: Dr Chris Turner, Emergency Medicine Consultant, University Hospitals of Coventry and Warwickshire, UK; Prof Eva Doherty, Director of Human Factors in Patient Safety, RCSI; and Prof Steven Yule, Chair of Behavioural Sciences at the University of Edinburgh, UK, at the third National Human Factors in Patient Safety Conference in RCSI

Julinda Schroeder reports on a recent RCSI conference which examined how non-technical skills can improve patient outcomes

To ensure the reliability and safety of surgery, and to reduce avoidable adverse events, the culture of the specialty needs to embrace non-technical skills.

This was the message from Prof Steven Yule, Chair of Behavioural Sciences at the University of Edinburgh, UK, speaking at the third National Human Factors in Patient Safety Conference recently held at the RCSI in Dublin.

Cognitive load

The theme of the conference was ‘It’s all too much: Cognitive load in the safe delivery of healthcare’. Prof Yule’s talk was titled ‘Biomarkers of cognitive load and non-technical skills’.

Explaining the importance of cognitive load in relation to professional performance, he referred to the University of Edinburgh’s multidisciplinary research programme, which aims to provide a scientific platform for advances in behavioural sciences, non-technical skills, human factors, and patient safety.

The driving force behind the programme is the Edinburgh sabermetrics group, a multidisciplinary group of surgical and social scientists, as well as other experts.

According to Prof Yule, surgical sabermetrics could be defined as advanced analytics of digitally recorded surgical training and operative procedures to enhance insight, support professional development, and optimise clinical and safety outcomes.

“Current research is implementing peer assessment, vision science, and smart checklists to objectively measure and improve the technical and non-technical practices that characterise surgical team behaviour,” he said.

He explained that some of these sabermetrics had already been embedded in surgery, by capturing videos of technical and non-technical skills and rating surgeons by peer assessors.

However, this method of assessment was expensive and labour intensive, while most medical professionals also faced serious time-constraints when it came to carrying out such assessments.

Using examples from surgery, sport, and space flight, Prof Yule illustrated how artificial intelligence could be used in the assessment of non-surgical skills.

In this regard, he explained that when an adverse surgical event occurs, it is important to assess what the cognitive load of the operating surgeon was like by evaluating the operating procedure.

“We do not have as much insight into our ability as we think and tend to overestimate our competency,” he said.

Some of the non-technical skills that were not currently being measured included communication, leadership, situational awareness, and decision-making actions, which all influenced the performance of the surgical team.

It was therefore necessary to make use of additional high-stakes tools for educational and research assessment in this area, he added.

Prof Yule explained that using sabermetrics to digitally record operative procedures in this way would support the outcomes of surgical procedures for both staff and patients.

The technology was already widely used in sporting disciplines such as baseball in the United States, to gather data and compile large databases on player performance. He explained how the technology could be transferred to any surgical environment to quantify intangible and variable aspects of performance objectively and continuously in real-time.

“[In other words] if you take one player out of your team and replace them with somebody else, what is the incremental difference in the potential for an outcome by doing that.”

He continued: “The grand challenge is to leverage some of these sporting technologies to enhance education, performance, and patient safety. In the last couple years, we have gained access to wide-scale, high quality, inexpensive video in clinical spaces to help us do that.”

Prof Yule added: “You need enough bandwidth to deal with what is in front of you. Our cognitive load is continually under threat from external factors and we often undermine our own cognitive capacity by engaging in [certain] practices.”


The second speaker at the event was Dr Chris Turner, Consultant in Emergency Medicine, University Hospitals of Coventry and Warwickshire, UK. The title of Dr Turner’s talk was ‘Why civility matters in a complex world’.

He is also the co-founder of Civility Saves Lives, which is a group of healthcare professionals aiming to raise awareness of the power of civility in medicine.

Dr Turner explained that everything medical professionals do for their patients required teamwork.​

In this regard, he said it had been found that incivility or rudeness reduced team functioning, clinical decision-making, and patient outcomes.

Although incivility could range from rude or unsociable speech or behaviour, the most important aspect was how it was interpreted by the recipient.​

Some of examples of incivility identified by Civility Saves Lives include: Shouting at someone; swearing; aggression (not necessarily towards someone); belittling someone; sending emails while in meetings; talking over others; being ‘difficult over the phone’; and rolling eyes, among other behaviours.

These behaviours have a direct impact on the recipient. He cited a 2013 study published in the Harvard Business Review, ‘The price of incivility’ (Porath/Pearson), which found ‘incivility’ can lead to a 61 per cent reduction in a person’s cognitive ability.

The study also found that 80 per cent of recipients lose time worrying about rudeness, 78 per cent reduced their commitment to work, 63 per cent lose time avoiding the offender, 48 per cent reduced their time at work, 38 per cent reduce the quality of their work, and 25 per cent took it out on others.

Dr Turner said that recognising the impact of incivility was the first step. The next step was acknowledging the issue and taking action to address it.​

Sharing some anecdotes from his own personal experience, Dr Turner explained that creating a positive work environment in which staff feel valued, respected and supported, reduced hospital standardised mortality rates.

It also reduced patient complaints, while improving staff satisfaction, staff performance, and the reported health of staff.​

“When someone is rude to us, it reduces our bandwidth; our ability to effectively juggle multiple tasks and conscious thoughts,” he said.​

According to Civility Saves Lives, the impact of incivility even affects those who observe the rudeness, resulting in a 20 per cent decrease in performance, and 50 per cent reduction in willingness to help others.

NICU study​

Dr Turner also referred to a study entitled ‘The impact of rudeness on medical team performance: A randomised trial’ (Risken and Erez et al), published in the journal Paediatrics in 2015. The study demonstrated the negative impact of rudeness on clinical outcomes.​

A total of 24 neonatal intensive care unit (NICU) teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotising enterocolitis.

Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by three independent judges (blinded to team exposure). The judges used structured questionnaires to assess team performance, information-sharing, and help-seeking.

The composite diagnostic and procedural performance scores were lower for members of teams exposed to rudeness than to members of the control teams. Rudeness alone explained nearly 12 per cent of the variance in diagnostic and procedural performance. A model specifying information-sharing and help-seeking as mediators linking rudeness to team performance explained an even greater portion of the variance in diagnostic and procedural performance.

“Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members,” according to the authors.

“Information-sharing mediated the adverse effect of rudeness on diagnostic performance and help-seeking mediated the effect of rudeness on procedural performance.”

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