Safer Surgery part 48 pps

Chapter 27 Behaviour in the Operating Theatre: A Clinical Perspective Nikki Maran and Simon Paterson-Brown As clinicians, we have spent many thousands of hours working in operating thea

Chapter 27 Behaviour in the Operating Theatre: A

Clinical Perspective Nikki Maran and Simon Paterson-Brown

As clinicians, we have spent many thousands of hours working in operating theatres over the last 20 years As a senior anaesthetist and surgeon, we recognize that we have a great deal of influence on the atmosphere created in the operating theatre and that our behaviour influences those around us However, as trainees

we experienced many different ‘regimes’ in a variety of theatres in which we were trained There has always been a steep hierarchy within any surgical team and there was no question but that the senior surgeon was the leader The only time this might ever have been in doubt was where there was an equally formidable theatre sister

or anaesthetist in post Voices were raised, instruments thrown, brows mopped and tears shed These were not environments in which one questioned decision-making or challenged leadership if one wished to set foot in the operating theatre again! We tended to work in small clinical teams or ‘firms’ with little turnover

of staff so everyone knew each other fairly well and teams became well oiled in

‘routine practice’ Although few protocols as we recognize them today existed, deviation from the team routine was seldom tolerated

Patients died, usually because they had co-existing medical disease and occasionally, due to some technical failure during surgery, at least these were the only things we measured Occasional emergency situations arose which resulted in a patient’s death and these ‘unfortunate’ events were often regarded as

‘unavoidable’ complications of surgery Occasionally a culprit was identified and usually publically vilified in departmental mortality meetings

As junior doctors, we provided continuity of care by working over 100 hours per week and specialist training lasted eight to ten years The major focus of training was in the development of good technical skills and these were honed to

a high level through an apprenticeship style of training by ‘practising’ on patients Examinations measured knowledge and everyone knew the trainees who were

‘good with their hands’ The system had massive training redundancy which gave us all plenty of time to ‘absorb’ the implicit skills which were not part of the curriculum – those of picking up cues in the clinical environment – Situation Awareness (SA), developing good clinical judgement – decision-making and developing our own teamwork and leadership skills by modelling our behaviours

on those demonstrated to us by our seniors Many of those who did not develop good SA or decision-making would fail to reach the senior registrar grade, however,

leadership behaviours, styles of communication and modes of teamworking were more subjective The development of non-technical skills (NTS) has therefore been

an implicit, though recognized, part of the medical curriculum for generations Although the focus of scrutiny in health care is often on failures and adverse events, we are well aware that, in clinical practice, many potential adverse events are avoided when individuals within the team pick up and act on early warning signs This phenomenon is recorded in studies (de Leval et al 2000, Catchpole et

al 2007) which demonstrate that high performing teams show greater ability to recover from minor errors

Over the last 20 years, the health service has changed enormously Medicine and surgery have become more complex, we are able to keep frail patients alive for much longer and so our patient population is becoming older and sicker This

is well summed up by a quote from Chantler who said that where ‘Medicine used

to be simple, ineffective and relatively safe, now it is complex, effective and

potentially dangerous’ (Chantler 1999, p 1181) We have learned from other high

reliability domains and are now aware that human factors are implicated in many

of the things which go wrong in hospitals and indeed in the operating theatre Indeed, the underlying causes of adverse events in healthcare are more likely to

be associated with behavioural failures than a lack of technical expertise (Bogner

1994, 2004)

Thankfully, ‘bad’ behaviour in the operating theatre has improved Throwing

of instruments and temper tantrums are now a thing of the past However, a recent survey of surgical trainees in Scotland revealed that in some areas as many as 50 per cent of trainees reported experiencing bullying by senior staff which made them feel unable to express their views (National Trainee Survey 2007), and this is clearly liable to influence how likely these trainees are to speak up if they observe problems in the operating theatre This finding is unlikely to be unique to Scotland

Streamlining of training has reduced the number of years for specialist training and introduction of the European Working Time Directive (EWTD) and similar limits to working hours in other countries has progressively reduced the number of hours that doctors are permitted to work While on one hand, reduction in hours of work has been demonstrated to reduce error in clinical environments (Lockley et al 2004), the increase in shift working increases the number of handovers of complex patient care and highlights the need for good and effective communication The reduction in hours of training time means that we no longer have the luxury of training redundancy and need to make all parts of the curriculum explicit While this has been done well for the knowledge and technical-skill-based competencies, there is now an urgent need to define the implicit skills (such as non-technical skills) required to work in the healthcare system and to embed them into the curriculum (Glavin and Maran 2003) The fixed ‘firm’ team has been replaced by transient teams of individuals who may come together for only short periods and once again this highlights the need for individuals to develop portable team skills,

or non-technical skills, which will equip them to work in these situations This

Behaviour in the Operating Theatre 447

book brings together, for the first time, the leading researchers who are carrying out observational research in the operating theatre We have been lucky enough to

be directly involved in the work of some of these groups and have learned much from the others It is useful, perhaps to consider how this work can be of relevance

to the operating theatre clinician

Some seminal studies (Brennan et al 1991, Vincent et al 2001) and government responses to these (Kohn et al 1999, Department of Health 2000) have helped us

to understand the importance of human factors in adverse events and have driven much of the patient safety agenda All of the researchers who have contributed to this volume have helped to increase our understanding of how non-technical skills influence the way we work more specifically in the operating theatre Increasing our understanding of where things are going wrong will help us to develop strategies to deal with these issues or to focus training on improving the situation Although we like to think that behaviour in the operating theatre has improved over the last ten years, it is sobering to look at the findings in observational work What is described is exactly what happens – it is just that it is so ‘normal’ that

we don’t notice how absurd our behaviour can sometimes be Many problems

in the operating theatre stem from the ineffectiveness or lack of communication (see Lingard et al., Chapter 17 in this volume) Although communication is a major component of undergraduate and postgraduate curricula, the emphasis is almost exclusively on doctor–patient or nurse–patient communication and very little if any consideration given to the importance of doctor–doctor or doctor– nurse communication This issue is now being addressed in various safety tools which are being introduced including the WHO patient safety briefing tool (World Health Organization) and the use of SBAR (Situation, Background, Assessment, Recommendation) (Leonard et al 2004) as part of the IHI initiatives in improving handovers

The non-technical skills taxonomies (Fletcher et al 2003, Yule et al 2006) which have been developed not only give us a vocabulary with which to express and discuss non-technical skills ourselves but also a framework which can be used to give feedback to help understand where we are and improve our own non-technical skills The definition of non-technical skills also helps to allow us

to integrate these skills into curricula (Canadian Patient Safety Institute 2005, National Patient Safety Education Framework 2004) and we will increasingly see non-technical skills being incorporated into workplace-based assessment Using these taxonomies in clinical practice (see Glavin and Patey, Chapter 11 in this volume) will help us to recognize when trainees are failing to develop good NTS early and introduce remediation Further research is needed to explore whether this can be effective and if not, this clearly has implications for selection in the future

Many of the research groups included in this volume are working in simulation environments The fidelity of the training mannequins which are now available means that the simulator is the ideal place to study behaviour in emergency situations without having to wait for these unusual events to happen in real practice

(Flin and Maran 2008) The same situation can be recreated on multiple occasions

to allow observation of cohorts of participants Although human factors training can commence in the classroom, in order to develop skills, individuals need feedback on behaviours and an opportunity to practise these skills The simulator provides an optimal environment which is safe for both patient and learner to allow observation of self and rehearsal of skills Simulators will clearly have a role to play in helping individuals to develop the skills required in emergency situations and are also likely to have a role in ‘remedial’ training The fidelity of the surgical simulators currently available is still not high enough to allow good intra-operative non-technical skills training for surgeons However this is likely

to be overcome in the next few years as the technology develops and simulators become more widely available Transfer of skills from the simulator to clinical practice is vital and NTS frameworks such as ANTS and NOTSS are designed to give feedback in both the simulated environment and in the operating theatre The development of our understanding of the impact of non-technical skills

on patient outcomes should also be reflected in the use of systems to analyse behaviours when errors occur such as during incident reporting and morbidity and mortality meetings The Australian AIMS study (Webb et al 1993) analyses critical incidents from a human factors perspective, but this methodology should

be more widely used

Challenges for the future include training trainers to become familiar with assessing and providing feedback on non-technical skill as (see Graham et al., Chapter 12 in this volume) have clearly demonstrated that inter-rater reliability of such systems is not high unless assessors are both experienced in the observation

of skills and have been well calibrated The aviation model of trainer accreditation for both teaching and assessing non-technical skills (Civil Aviation Authority 2003) is one that we can only aspire to in healthcare

We have come a long way in healthcare over the last ten years and many of those who have contributed to this book have helped to drive this change In the next ten years, non-technical skills will become an implicit part of the curriculum for doctors, nurses and all other health professionals involved in the delivery of healthcare As a result, the assessment of non-technical skills will become the norm, and understanding the importance of non-technical skills in certain specialties will drive the need to identify individuals with good NTS early in training for selection

to certain specialities Future generations will find the operating theatre a very different place to work in and, as a result, ultimately a safer place for patients

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Brennan, T., Leape, L., Laird, N.M., Herbert, L., Localio, A.R., Lawthers, A.G., Newhouse, J.P., Weiler, P.C and Hiatt, H.H (1991) Incidence of adverse

Behaviour in the Operating Theatre 449

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Development of a rating system for surgeons’ non-technical skills Medical

Education 40, 1098–104.

A-TEAM 129

behaviour categories 132

development of 136–7

feedback 138

in the operating theatre 141–4

rationale 130–36

summative assessment 138, 141

training 137–8

adverse events 12–13, 151, 445, 446–7

all team members’ behaviour scale see

A-TEAM

alpha-amylase analysis 377–8

American Society of Anesthesiologists

(ASA) scores 264

anaesthesia

adaptive coordination 204–15, 225–33

observation systems 228–33

task-analytic approach 234

behavioural markers 308–9

clinical guidelines 371–80

coding reliability 230–31

collaborative management of

unexpected events 225–8

communication 241–55, 311–15, 316,

399

coordination behaviour 203

data recording 230

emergence 246–9

experts’ judgement 309

handover from 249–55

human factors 305

induction 244–6

nonroutine events (NRE) 205

observation evaluation tools 308–10

observational studies 231–3

participants in study 306

problem solving 303–5

shared mental models 315

simulators 304

study results 311–12

teamwork 203–4 training scenarios 306–8 transitions 244

Anaesthetists’ Non-Technical Skills System (ANTS)

development 176–7 information gathering 181–2 intraclass correlation (ICC) 195 lessons learnt 199–200 methodology 190 misclassification 198 promotion of 177–9 qualitative data 196–9 questionnaires 196–7 rater training 193–5 safety standards 198–9 study design 190 taxonomy 209, 214–15 teaching 180–83 trainee assessment 185–6 video 190–93

workplace-based assessment 179–80, 189–200

ANZCA (Australian and New Zealand College of Anaesthetists) 189 ASA ( American Society of

Anesthesiologists) 264 audio-video recording 388–90 Australian and New Zealand College of Anaesthetists (ANZCA) 189 behaviour scales and teamwork 130, 132–4

Behavioural Marker Risk Index (BMRI) 266–7, 271–2

behavioural markers 263, 273, 423–35 anaesthesia 308–9

Non-Technical Skills for Surgeons (NOTSS) 14

rating of 194–5

scores 270–71

systems 85, 263

BMRI (Behavioural Marker Risk Index)

266–7, 271–2

CanMEDS 353

Case Based Discussion (CBD) 180

CIT (critical incident technique) 13

clinical competence, assessment of 28

clinical environment, interruptions 406

clinical guidelines 371–2

observations 374–5

simulator-based evaluation 372–4

Cognitive Task Analysis 14

commodity approach to healthcare 442

communication

anaesthesia 241–55, 311–15, 316, 399

operating theatre (OT) 118, 286–8

problem solving 301–16

surgery 273–4

surgical performance 283–97

teamwork 143–4, 156–7, 283–97

coordination behaviour 203

cortisol analysis 377

costs of incidents 169

crew resource management (CRM) 67,

153–5, 302, 423–5

in aviation 425–6

healthcare 433–5

in medicine 426–33

critical incident technique (CIT) 13

CRM see Crew Resource Management

making see surgical

decision-making

Directly Observed Procedural Skills

(DOPS) 180

Disruptions in Surgery Index (DiSI) 408–9

DOPS (Directly Observed Procedural

Skills) 180

double-loop learning 155

emergency department, interruptions

406–7

environmental psychology 406

ergospirometry 375–7

European Working Time Directive 8, 29,

274

failure source model 322, 329–31 followership 134–6

heedful interrelating 207–8 ICC (intraclass correlation) 195 Independent Sector Treatment Centres (ISTC) 29

infant simulators 372–4 innovation 438

instrument nurses see scrub nurses

INTERACT 209 intraclass correlation (ICC) 195 ISTC (Independent Sector Treatment Centres) 29

JA (Judgement Analysis) 364–6 JARTEL (Joint Aviation Requirements: Translation and Elaboration of Legislation) project 14 Judgement Analysis (JA) 364–6 Kaiser Permanente, surgical safety programme 274–8 latent failures 151 leadership 134–6, 154, 445 learning, double-loop 155 Line Operations Safety Audit (LOSA) 85,

424, 433 logistic regression model 267 Mini Clinical Evaluation Exercise (MiniCEX) 180, 183 music in operating theatres 410–11 noise in operating theatres 410–11

non-technical skills (NTS) see also

Non-Technical Skills for Surgeons (NOTSS); Oxford NOTECHS system; Surgical NOTECHS anaesthesia 175–6, 186 crew resource management 67–8 nurses 68

orthopaedic surgery 335 patient safety 301 surgery 103 surgical training 7–9, 21–2

Index 453 Non-Technical Skills for Surgeons

(NOTSS) 8–21, 49, 113

adverse event and mortality reviews

12–13

attitude survey 11

behavioural markers 14

critical incident reviews 13–14

development of 14–15

future research 22–3

literature review 10–11

observations 12

Procedure Based Assessments (PBAs)

44

project design 9–20

rating scale 15

system evaluation 15–17

system usability 17–20

task analysis 9–14

user handbook 17

nonroutine events (NRE) 205

NOTECHS 105 see also Non-Technical

Skills for Surgeons (NOTSS);

Oxford NOTECHS system;

Surgical NOTECHS

NOTSS see Non-Technical Skills for

Surgeons

NRE (nonroutine events) 205

NTS see non-technical skills

Nurses’ NOTECHS 67–8

communication 69–70, 74

consultant surgeon interviews 77–8

decision making 72–3, 76

expert panels 78

leadership 72–3, 76

literature review 68–73

scrub nurse interviews 73

situation awareness 71–2, 76

teamwork 70–71, 74–6

Objective Structured Assessment of

Technical Skill (OSATS) 48–9

observational methods 130–31, 263–4

Observational Teamwork Assessment for

Surgery © (OTAS © )

assessment process 90–95

behaviour ratings 88, 89

development 87–8

holistic assessment 97

non-teamwork surgical processes 96 observation 113

observer’s expertise 96 Oxford NOTECHS system 111 phases 88–9

retrospective rating 96 simulation-based team training 96 task checklist 88, 89

team feedback 89–90 team orientation 89 teamwork 84–7, 95

OCAP see Orthopaedic Competence

Assessment Project

operating room see operating theatre

Operating Room Management Attitudes Questionnaire (ORMAQ) 11 operating theatre (OT)

bad behaviour 446 communication 286–8 crew resource management (CRM) 155

distractions 405–15 environment 406 interruptions 405–15 music 410–11 noise 410–11 observation 387–8 prospective memory 340–41 silence 288–96

teamwork 153 telephones 334

OR see operating theatre

ORMAQ (Operating Room Management Attitudes Questionnaire) 11 Orthopaedic Competence Assessment Project (OCAP) 40, 42, 43–4 orthopaedic surgery 321–36 cases 322–3

distracters 334 dual observers 331–3 equipment 335 expert observers 335 failures 323–9, 333 index procedures 34 non-technical skills (NTS) 335 patient safety 333–5

Surgical NOTECHS 107 teams 322–3