Safer Surgery part 33 potx

There was a sense that the scrub nurse, the student scrub nurse, and the circulating nurse this was a more novice circulating nurse; the senior circulating nurse from the preceding case

questions (Can you manually adjust white balance? Let’s try again Can you adjust the colour?) The circulating nurse hears and acts on these questions but never articulates or announces her actions She eventually goes to call for help; this time she announces that she has called The OR-coordinator arrives and then the PSA OR-coordinator leaves PSA arrives, [fiddles] with controls for a while (though it seems he doesn’t have any solutions) The staff surgeon finally asks again: ‘Are we getting another tower?’ The circulating nurse pages a second PSA, returns and asks this PSA if there’s another in the office The circulating nurse disappears without indicating that she’s going Second PSA arrives and mumbles about being in six rooms, can’t hear the pages The staff surgeon asks the first PSA about the resolution PSA1 says they can bring another or turn this one off and on again They try turning off and on, with no success Third screen arrives (a second was rolled in earlier but nobody pointed it out) PSA1 and the circulating nurse (who is now back in the room) set up new screen at 11:30am.

Observer notes: This seems to be primarily a style problem Neither staff

surgeon nor (especially) circulating nurse speaks very assertively in naming and navigating the situation There seems to be less communication than needed for efficient resolution of the problem I’ve also recorded this as a ‘content’ failure

to capture that element of the exchange Relevant information seems lacking (for example, status of attempt to fix the problem, plan to fix the problem, opinions about what should be done).

As this observer notes, the silences in this communication exchange seem attributable to personal ‘style’: some team members are more ‘quiet’ than others

In fact, volume and degree of communicative involvement – particularly the consistent patterning of who speaks more loudly and who speaks more quietly

in the OR – is a function of social structures and power relationships, not only an issue of personal preference

Degree of communicative involvement can be a cultural – as well as a personal – pattern Survey research by Sexton et al (2000) suggests that surgical culture discourages questioning and cross-checking across the team’s hierarchical layers, which can create an involvement where team members are more likely to speak when spoken to than to offer comments or questions Examples in the field notes suggest that this culture persists, particularly in instances where a volunteered question or comment reveals ignorance or mis-assumptions:

As the surgeons close, the anaesthetist asks if they still have to do a stoma The staff surgeon replies: ‘We’re not doing a stoma today doctor We’re taking away the stoma He came in with one and he’s leaving without it.’

The anaesthetist’s question reveals his ignorance of the surgical procedure and wins him public ridicule, confirming that it would have been prudent to keep quiet Medical sociological studies of uncertainty (Fox 1957, Lingard et al 2002a) draw

attention to the tacit prohibitions against advertising what one does not know, and this cultural value likely shapes patterns of silence in an interprofessional and hierarchical environment such as the OR

A third pattern of silences emerges in the Content failures category: team exchanges in which barely concealed conflict or anger simmers persistently but

is never addressed The following field note excerpt illustrates the issue of silence and tacit conflict:

I think that the failures scale underestimated the communication problems for this case There was a sense that the scrub nurse, the student scrub nurse, and the circulating nurse (this was a more novice circulating nurse; the senior circulating nurse from the preceding case was out of the room for much of this one) were not being effective at handing equipment or solving problems I was aware of this, but the room remained quite quiet, and I was only able to document the issues in three failures At the end of the procedure, the surgical fellow told me that she ‘was boiling inside’ for the whole case ‘Usually they’re at least paying attention Today, it was like, “Hello! We’re operating here” I worry, based on the fellow’s comment, that my observational skills weren’t sharp enough today – but I also think that the surgeons internalized their frustration, so it was difficult

to capture it through communication records.

This example crystallizes the issue of tacit communication Although the room was silent for much of the case, the observer could sense the conflict and tension in the room, a sense confirmed by the fellow’s comments Such lurking tensions can pose grave difficulties for effective collaboration, yet they are difficult to capture

in terms of a rating of explicit communication

uncategorized Silences

We have focused so far on the kinds of silences that our evaluative tool does manage to capture to some degree While these examples illustrate the complexity

of interpretation in assigning meanings to silence, another set of examples also require consideration: those for which our tool offers little or no basis for documentation For example, in some observed cases there is no evidence on which to ascribe meaning to silence – just a description that there is no talk among team members: ‘The case proceeds uneventfully but there is no talk at all between professions before the case begins.’ Is this silence problematic? Certainly we have seen cases where such interprofessional silence is problematic, but we have also seen instances that suggest a team’s non-verbal fluency In one case, a nurse suggested pride in such silent team fluidity, announcing cheerfully to the team,

‘Let’s see if we can do the whole case without talking’; in another case a surgeon noted to the observer, ‘Did you catch all of that non-verbal communication?’ Instances of complete silence present such ambiguity that we cannot confidently

assign them a category in our evaluative tool; therefore, if they are problematic, they are lost from the communication failures database And, because our field note descriptions of complete silence are so lean, we are equally unable to satisfactorily capture their productive functions

Summary and implications

Our approach to evaluating team communication is based on the premise of assessing communication within its social context, interpreting rather than eliding the richness of communicative events that emerge, overlap, evolve, echo, resolve, abort or die away Within such complex discursive webs, we have faced the challenge of addressing the relationships between communicative presence and absence – between speech and silence This chapter is a preliminary description of that challenge, not in an attempt to offer conclusions or gain closure, but rather to interrogate and open up this complexity in communicative performance data This chapter foregrounds issues of interpretation rather than risking the perils

of taking a literal approach to language: silences are meaningful but ambiguously

so, and we have laid out our interpretive logic based on the rhetorical framework underpinning our evaluation tool Our framework of audience, content, occasion and purpose is a way of categorizing communication failures that draws our attention to certain forms of communicative presence: an untimely instrument request, for instance, or a repeated question that rises in urgency As we have described, in attending to the presence of such speech events, our attention is also drawn to the silences intertwined with them: the absence of an earlier, more proactive request or the absence of a response to the repeated question In fact, our framework may impose a useful structure that helps render such silences ‘visible’ when they might otherwise escape observer’s evaluative attention, particularly in relation to two areas of our framework (purpose and content) where silences tend

to recur However, we acknowledge that other patterns of silence do not so readily surface within our framework, and further critical attention needs to be paid to delineating the interpretive challenges associated with these

The examples we consider illustrate that silence is neither straightforwardly

‘good’ nor straightforwardly ‘bad’ Silence can reflect a lack of communication

– an absence or gap in the chain of communication, such as when a request is not heard by a team member But silence can also function as a communicative act that implies support, willingness to assist, inviting another to speak, keeping the peace, or pausing to reflect And it can function as the operationalization of power relations, such as when a team member is ‘silenced’ by another’s speech or the silence in the OR environment is oppressive, suggestive of unvoiced emotions running beneath the surface

Because silence is often a communicative act, an important part of team members’ communicative expertise is their ability to interpret and use silence For instance, expert nurses possess a form of situation awareness that allows them

to distinguish the right moment to interrupt the surgeon’s silent concentration with questions Similarly, decisions about what, when and how much to update

on ‘in-progress’ issues likely involve a weighing of the desire for clarity and the prohibition against ‘cluttering up’ an already complex communicative environment with low-value messages such as ‘ultrasound hasn’t called back yet’

Understanding silence as more than communicative absence requires the assignment of meaning based on social and ecological cues: a complex but necessary endeavour if we are to achieve an authentic and ecologically valid assessment

of communicative performance As we account for silence in the evaluation of communication failures as an outcome in a team briefing intervention, there are two key interpretive dangers We can underestimate communication failures by not accounting for silences at all or by misreading them as productive when they are not, or we can overestimate communication problems by misreading silences

as problematic when they are not Further, we can distort the distribution of failure types by forcing an assignment of meaning in a particular direction, such as interpreting all requests-without-responses as purpose failures when in fact silence may send a tacit message that resolves the question’s purpose In our own work,

we have used spontaneous interviews whenever possible to judge the meanings of silences for which contextual cues are ambiguous or lacking; however, this is not always a viable technique for performance assessment

Silence is intimately linked to speech in complex communicative environments like the operating room While the evaluation of a team’s communicative performance traditionally focuses on what observers can see and objectively label, we need to pay attention to the interplay of speech and silence and articulate our logical frameworks for assigning meaning to silence ‘Counting silence’ is a complicated but necessary business for performance evaluation for safer surgery: silence can promote safety when team members ‘count to ten’ and think before acting, and it can undermine safety when team members fail to cross-check and respond to one another’s questions We hope that our reflection on the patterns

of silence as they emerge within the rhetorical framework of our evaluation tool will prompt surgical performance researchers to consider the problem of silence, towards carefully theorized and situated accounts of its role in teamwork

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Observing Team Problem Solving and Communication in Critical Incidents

Gesine Hofinger and Cornelius Buerschaper

introduction

Although a relatively recent research area, we are beginning to understand the significance of human factors for patient safety, especially the role of interpersonal skills (e.g., Fletcher et al 2003, Kohn et al 1999) and the importance of non-technical skills on non-technical outcome factors (Mishra et al 2008, Reader et al 2006)

Many efforts to improve non-technical skills have been made in different domains; for example the crew resource management training (CRM) in aviation, and adaptations in healthcare CRM training was designed to strengthen team-related skills for decision-making in critical situations and to enhance safety during routine situations (Cannon-Bowers et al 1995, Jensen 1995, Merrit and Helmreich

1997, Wiener et al 1993) In unexpected situations, standard operating procedures (SOPs) do not help so then crews need to actively solve problems Thus, the idea

of CRM includes problem-solving and team skills or, rather, communication and teamwork are seen as means for good decision-making in the cockpit One concept that combines communication, teamwork and problem solving is that of ‘shared mental models’ (Cannon-Bowers and Salas 2001, Klimoski and Mohammed 1994, Schöbel and Kleindienst 2001)

Sharing mental models is critical for team problem solving because it is the process by which problem solving becomes a team activity ‘Problem solving’

is a thinking process that integrates perception and processing of relevant clues from the environment (like a sudden drop in a patient’s blood pressure), the development of a plan and the decision for one option Being a thinking process it

can be observed only by observing speech acts accompanying thought (‘thinking

aloud’) or overt behaviour This is true for team members as well as for researchers

So, team problem solving can only occur if people share relevant thoughts using explicit communication

Shared mental models enable members of a team to gain a shared understanding

of the task and to cooperate accordingly The shared understanding of the problem allows all the participants in the operation to remain ‘in the loop’ Team research

has highlighted the importance of shared mental models for team performance (Entin and Serfaty 1999, Orasanu 1990, Stout et al 1999)

As we see it, healthcare has willingly adopted the idea of training for team-related skills in medically critical situations (Davies 2001, Glavin and Maran 2003, Howard et al 1992, Risser et al 1999, Thomas et al 2004), without putting much emphasis on the process of problem solving Good decision-making on the other hand is a result of adequate problem solving There is a long-standing tradition of problem-solving research in psychology (e.g., Dörner 1996, Frensch and Funke 1995), but little of that has been translated into the field of healthcare

Research into CRM courses shows that some training programmes lead

to measurable results and some do not In spite of the diversity of results, we can conclude that CRM training in general has proven to be useful in terms

of changing behaviour and values, and that it can improve the efficiency of teams (Morey et al 2002, Salas et al 2001, 2006) Yet what we do not seem to fully understand is how improved communication skills in teams and improved decision-making interact

One pre-requisite of evaluating CRM training programmes is the development

of tools for measuring behaviour The use of behavioural markers is now a widely accepted approach in aviation (Häusler et al 2004, Transportation 1998) where in many countries the evaluation of CRM skills has become part of the licence check (e.g., Joint Aviation Authorities 2006) Also in healthcare, over the last decade many research groups have developed sets of behavioural markers for team-related skills (e.g., Carthey et al 2003, Fletcher et al 2004, Gaba et al

1998, Thomas et al 2004, Undre et al 2007, Yule et al 2006) The behaviours covered are similar; communication, team leadership and decision-making are always part of the set

Thus, it seems possible to measure CRM performance in terms of the team showing certain classes of behaviour more or less adequately But there is still a lack of knowledge about what actually happens while a healthcare team is solving problems, e.g., in an incident in the operating room (OR) How do they approach the problem? How do they find a decision? Do they negotiate goals and plans? Do they actively build shared mental models by talking about their perception of the problem?

Being psychologists interested in action and in problem solving we carried out, together with anaesthetists, an observational study on problem solving in critical incidents in the OR We aimed to understand the process of problem solving in

a team, so we developed two tools for the observation and evaluation: one for problem solving in the team and a very specific behavioural marker system for communication in defined critical incidents The observational study was part

of a research project on the development and evaluation of training of problem solving which was funded by the German Federal Ministry of Education and Research Here, we report only our approach to observing problem solving and communication in the OR

Observing Problem Solving and Communication in Anaesthesia

Concept

Good problem solving skills are essential for team members in dynamic, high risk domains such as the OR Since this is especially true during unexpected events we focussed on observing critical incidents within the OR

Communication is an essential part of team problem solving and is also important for the creation of a cooperative team atmosphere, for the maintenance

of professional identity, and the exchange of information to coordinate routine activities (St Pierre et al 2007) But in critical situations like incidents during an operation, communication must, above all, serve to establish and maintain a shared understanding and coordinate behaviour; the other functions of communication become secondary (a cooperative team atmosphere, e.g., must be established

before an incident).

When incidents in the OR occur – at least in the German hospital system – the anaesthesiologists are often responsible for coordinating the overall situation This includes conferring with the surgeons, but also with the anaesthesia assistants, whose integration is essential Additionally, contact must be maintained with superiors, the laboratory, the blood bank, and the intensive care unit Anaesthesiologists plan their own behaviour and organize the team Thus, they have a central function for the problem solving processes in the system OR For this reason, the study presented here focuses on anaesthesiologists

As said above, little is known about the communication behaviour in the OR Analogously to many studies of cockpit communication (e.g., Dietrich and von Meltzer 2003, Sexton and Helmreich 2000), some studies of communication

in operations (e.g., Grommes 2000) have focused on the structures of language and their potential to distort communication (linguistic approach) The other approach to communication in the cockpit, the socio-psychological approach, has rarely been pursued for operations (but see Coiera and Tombs 1998) This approach understands communication as a behaviour correlate of specific attitudes, personality traits, etc and correlates it with the team’s achievement:

‘It investigates which communicative patterns contribute to effective teamwork.’ (Silberstein 2001, p 5)

Behaviour during incidents in the operating theatre is difficult to investigate, because (at least in Germany) there are no recordings of all events in all operations, in contrast to the cockpit voice recorder and ‘black box’ in aviation Field observations would be uneconomical due to the low frequency of critical incidents Furthermore, in real crisis situations, the presence of an observer may

be a distraction

For this reason, the study presented here captured on video and analysed incidents processed in the anaesthesia simulator In the setting used for this study, the surgical side of the simulator is not realized so the surgeons and nursing staff simply play a role The nursing staff’s field of activity during