Safer Surgery part 34 ppsx

This includes the organization of behaviour and the coordination of the team: establishing shared mental models, conveying and requesting information, defining goals, planning, deciding,

anaesthesia is also only partially represented The specialized field of activity for the anaesthesiologists is thus more realistic than for the other occupation groups Since the content of the communication is determined by specialist activity, in this study we investigated only the anaesthesiologists’ communication, not that

of the surgeons or the nursing staff

Anaesthesia simulators, like most flight simulators, are high fidelity simulators These offer the advantage of allowing a relatively standardized way of observing how incidents are dealt with Complete standardization is not possible, because the behaviour of the anaesthesiologists influences the further course of the incident The analysis of such scenarios thus faces the same problems as does problem-solving research with highly complex computer-simulated scenarios (see Dörner

et al 1983)

Behaviour in simulator scenarios can already deviate from real operation situations because, in calm beginning phases, the participants are more prepared for critical events during an operation Additionally, at least at the beginning, the participants are aware that they are in an observation situation For this reason, utterances that often occur in calm phases of real operations, like jokes, lessons, and private conversation (Pettinari 1988), are rarely heard Despite these limitations, physiologically and as an operation setting for anaesthesiologists, the simulator is at least apparently valid In the scenarios we used (cf Section 2.3), the anaesthesiologists exhibited a high degree of involvement which was confirmed in self reports (St Pierre et al 2004) This high degree of the participants’ involvement during ‘hot phases’ of the scenario suggests that here they used their customary communication strategies, especially to coordinate with the nursing staff and surgeons

Research Questions

The study presented here investigated how anaesthesiologists in critical situations

in the simulator communicate with their nursing staff and the surgeons The focus

of the investigation is on the analysis of the anaesthesiologists’ utterances arose during the processed scenarios, focussing on communication This includes the organization of behaviour and the coordination of the team: establishing shared mental models, conveying and requesting information, defining goals, planning, deciding, control, conflict management, reflection, etc Special attention is paid to the interaction with the surgeons Here, we pursued three issues:

Description of the Communication (Exploratory, Descriptive Question) Since

there are so few studies of communication in operations, we first investigated what general kinds of utterances arise in the processed scenarios A focus is on communication related to problem solving

We were also particularly interested in finding out whether clinical experience, gender or the kind of scenario had an influence on the kinds of utterance

Connection between the Categories of Communication and the Quality of Medical Management (Hypothesis-testing and Exploratory Question) The

results of human factors research in other occupational fields permits us to deduce the hypothesis that the quality of medical management is connected with communication We therefore ask: how does the communication behaviour

of anaesthesiologists differ under good and bad medical management in the scenarios?

Quality of Communication in Critical Situations (Exploratory Question, Normative Approach) During the scenario’s critical situations, the communication was

evaluated in terms of previously formulated behavioural expectations (behavioural markers): did the anaesthesiologists exhibit the type of communication behaviour that psychological and medical experts would expect in a team problem-solving process?

Method

Data Background: The Training Study ‘Human Factors in Anaesthesia’

With cooperation between the Simulator Centre of the Anaesthesia Clinic at Erlangen University Clinic and the Institute for Theoretical Psychology, a curriculum for physicians training for their specialization, ‘Human Factors in Anaesthesia’, was developed (St Pierre et al 2004) This combined previously introduced simulator training for crisis management and psychological training modules on specific human factors topics The psychological trainers are also involved in the feedback about the processing of anaesthesiological crisis scenarios in the simulator For the first module, ‘communication and cooperation

in the OR’, three scenarios were developed that made specific demands on team problem solving and communication while dealing with incidents This made it possible to evaluate not only the medical competence of the participants, but also their team-related problem-solving competence Thus, the desirable integration

of non-technical abilities (e.g., communication in an interdisciplinary team) and specialized procedures (e.g., stabilizing blood pressure) was achieved The first module of the curriculum was evaluated in an experimental design with a test group and a control group The control group received a lecture on human factors in anaesthesia instead of the training unit They worked through the same simulator scenarios For a more detailed presentation of the study and of the training evaluation, (see St Pierre et al 2004) The scenarios both groups worked through in the course of training were used for the evaluations presented here, because few differences were to be expected within the training (any differences are highlighted in this chapter)

The participants in the study were 34 interns at the University Clinic for Anaesthesiology in Erlangen This was a random sample, except that women and men were distributed evenly between the two groups and among the training sessions Because the sample was small, the participating women worked through Scenario 2 whenever possible This means that the effects of sex and scenarios are confounded, but recognizable Despite the partly chance allotment, it was possible to obtain homogeneous partial samples, with the exception that the individual scenarios were differently filled in terms of the sex and experience of the participants Clinical experience ranged from one to six years with a mean

of 3.3 years Men and women did not significantly differ in their mean length of clinical or in simulator experience

Scenarios used

For the training programme, the following scenarios were developed so as to make specific demands not only on the management of a medical incident, but also on problem solving and communication in the team Each scenario (detailed below) was designed to take 30 minutes (the actual duration of the scenarios ranged from

16 to 42 minutes)

The training programme’s three scenarios were each worked through by one participant, each supported by a real nurse Simulator staff assumed the role of the surgeon, sometimes supported by a participant The scenarios are based on a script that calls for fairly standardized communication from the instructed role-players in predetermined critical situations For example, after a drop in blood pressure, the surgeon asks one of the anaesthesiologists whether he or she ‘isn’t managing back there’ If the participant ignores the question, the script prescribes as the surgeon’s

Proportion of participants with

Table 18.1 Sample of the sample

‘answer strategy’ that he or she ‘exert verbal pressure’ But if the anaesthesiologist communicates a problem, the script instructs to offer cooperation

The participants judged all three scenarios to be adequately realistic and to be stressful On a five-step Likert scale (1 = very realistic, 5 = not realistic at all), the means for evaluated realism were between 1.8 and 2.55 (n.s.); on a ten-step Likert scale (1 = boredom, 10 = overburdening), the stress caused by the scenario was reported as between 5.3 and 7.6 (n.s.) While extreme stress would deteriorate participants’ ability to problem solve whereas boredom would mean that they did not experience a critical situation (but instead routine), the medium stress levels reported seems to indicate that participants were challenged but not working at their limit

Scenario 1: Laparoscopic Cholecystectomy with Volume Deficiency Reaction and Air Embolism

In a laparoscopic cholecystectomy, the abdominal cavity is filled with CO2 gas

to provide the surgeon with better visibility If the abdomen is inflated too much, less blood can flow back from the abdomen to the heart, resulting in lower blood pressure and a faster pulse This is the first complication in the scenario After the therapy, which requires close communication between the surgeon and the anaesthesiologist, operative inattention leads to bleeding in the abdominal cavity CO2 gas flows into the bloodstream and results in an air embolism The anaesthesiologist must recognize this situation, which is acutely life-threatening for the patient, and plan the therapy, in which the surgeon must be integrated The therapy consists in administering medications that stabilize circulation and,

if appropriate, changing the operating procedure, organizing transesophageal ultrasound and transfer to the intensive care unit (ICU)

Scenario 2: Occluded Perforated Abdominal Aorta Aneurysm

This clinical picture is an aneurysm of the main artery in the upper abdomen (acute intense pain) The aneurysm tears or bursts, resulting in a life-threatening situation This is the situation in this case

The anaesthesiologist must rapidly coordinate the operating procedure in close discussion with the surgeon and the nursing staff and attempt to stabilize circulation with the aid of providing volume (blood, infusions) and medications supporting circulation (catecholamines) Special communicative demands arise if clamping off is too fast or if the surgeon opens the aorta In the end, the patient should be sent to the intensive care ward in a stable state

Scenario 3: Lung Embolism after Speculum Examination of the Knee in the Recovery Room

This scenario is about a postoperative complication resulting from vascular congestion The clinical picture develops suddenly when the bloodstream carries a

blood clot (thrombus) into the lung, where it blocks a blood vessel Thus, a section

of the lung is no longer supplied with blood, and no gas exchange occurs here The blood backs up to the heart and the heart muscle is acutely overburdened, resulting

in circulatory failure and intense pain

The anaesthesiologist is called to a patient (who has had a knee operation)

as an emergency and must familiarize him or herself with the situation, collect the necessary information and then organize the therapy Treatment includes firstly, applying medications that support circulation, anaesthesia and respiration and thereafter, medications that reduce blood clotting But, the use of such a thrombolytic after surgery must be discussed with the surgeon For the severity of the embolism and the state of therapy to be judged, a number of specialists must

be brought in and their judgements discussed

Observation evaluation Tools

The analysis of the scenarios is based on the methods of evaluation described in the following:

a system of categories, ‘problem solving in a team’

behavioural markers for specific communication behaviours

experts’ judgement of medical management

A Tool for Observing Problem Solving in the Anaesthesia Team

A system of categories, ‘problem solving in a team’, was developed to categorize everything uttered in each scenario It comprises 24 categories organised into five

‘overarching categories’ labelled: (i) formal characteristics of the statement, (ii) organization of activity, (iii) relation the team and of processes, (iv) conflict management and (v) other The development of the system was oriented toward the phases of action organization, as developed by Dörner (1996), and toward considerations emerging from research on solving complex problems in groups (e.g., Stempfle and Badke-Schaub 2002, 2003) It was supplemented by inductive category formation on the basis of video data from the anaesthesia simulator Every remark was classified on the formal level and in one of the other four overarching categories Randomness-corrected observer agreement on these categorizations reached 61 percent–80 percent (Cohen’s Kappa) Table 18.2 shows the overarching and subsidiary categories

Behavioural Markers for Specific Communication Behaviour

Behavioural markers for communication were developed Behavioural markers are behaviour patterns whose presence in a stream of behaviour indicates certain skills For the present evaluations, anaesthesiologists and psychologists developed

a set of behavioural expectations based on the scenario scripts Studies using

•

•

•

behavioural markers often report low inter-rater reliability, but for our project, which aims to evaluate a training programme, a high concordance between observers was essential So, we decided to formulate a set of very specific markers They describe communicative behaviour required to solve a scenario optimally, for example the insistence on a slow de-clamping in the aorta aneurysm scenario

A list of behaviour-oriented observable items was developed that operationalizes the necessary communication competencies

The demands of each scenario were different, so 16 to 22 different markers were defined for each scenario Two observers judged the presence of each marker

in each person in the scenario (possible answers: yes, no, not applicable) The randomness-corrected observer agreement here was 82 percent (Cohen’s Kappa) This shows that it is easier to achieve good inter-rater reliability using more specific markers (but of course, the marker set has to be defined for every scenario that is evaluated) Examples for the behavioural markers used are shown in Table 18.3

Experts’ Judgement of Medical Management

Two anaesthesia experts also independently judged the medical management of the scenarios The experts were not aware that the videos were being evaluated in

Overarching category Categories

Formal characteristics Question, statement, directive/order, other New unit of activity, addressing the surgeon on own

initiative

Organization of activity

Information gathering, model formation, conveying information (facts), decision, explanation of own activity, commentary on activity, conveying problem and situation, conveying problem and situation with model, redundance, control, confirming understanding, hypothesis, anticipation, goal, plan

Relation to team and process Utterances related to team and relationship, process organization

Reflection/emotional utterances/own feelings a Conflict management Offer to engage in conflict;objective, escalating, ignoring, de-escalatingb anaesthesiologist: Other

a Because pure utterances of reflection were not expected, these categories were bundled together.

b This is the only category that considers the surgeon’s utterances, because a conflict always arises from interaction All utterances that could be considered offers to engage in conflict were counted.

Table 18.2 Category system ‘Problem solving in a team’

accordance with the aforementioned tools Differing observations were discussed until agreement was achieved (communicative validation, e.g., Bauer and Gaskell 2000) For each phase of each scenario, a system was used in which points were given for quality of therapy, diagnostics, and, where applicable, monitoring Each item could be scored from 0 to 2 points (bad to very good), which resulted in scores between 16 and 24 points for the scenarios Table 18.4 shows the eight evaluation items for Scenario 1

Some Results

As studies on problem solving or the analysis of thinking processes in the medical field are rare (but see Gaba 1992), we started with explorative questions We were able to formulate hypotheses concerning the field of communication We would like to highlight some of the findings of our analysis that helped us improve our training programmes In short:

Critical situation in

accordance with script Behavioural marker

Scenario 1

Before the OP Gives the OK for the OP only after his/her own preparations are completed

Changed position (head

raised, feet lowered)

Anaesthesiologist conveys concern to the surgeon early

Anaesthesiologist asks for a change of position/release of pressure

Scenario 2

Cut Requests rapid clamping or conveys problem

Asks the surgeon to report

Clamping Intermediate briefing with nurseImprovement of circulation conveyed to

surgeon

Scenario 3

Anaesthesiologist

enters recovery room

Anaesthesiologist asks nurse what has happened

Responsible superior is informed

Surgeon rejects heparin

Anaesthesiologist remains objective Anaesthesiologist conveys reasons (acute danger to patient, life takes priority over knee … vital problem)

Table 18.3 examples of behavioural markers for evaluating communication

in the scenarios used

Anaesthetists talked more often than they expected they would across all scenarios

Almost half of all utterances help pacing or establishing shared mental models

We found nearly no explicit addressing of the team

There was nearly no talking about aims and plans (of more than one step) There were very few real questions

We found a high correlation (.56) between the quality of clinical management and communication measured with the behavioural markers

In reporting some results, we will give the explorative questions that lead us in the analysis followed by the answer

Description of Communication

Amount and Type of Utterances

How much do the participants talk, and what kind of remarks do they make? The anaesthesiologists spoke more during the scenarios than even they themselves expected: in preliminary talks, the intention to investigate communication during operations was repeatedly belittled as senseless on the grounds that there is little speaking during an operation (which also contradicts our observations of operations) There was a mean of 228 utterances per person; with an average scenario duration

of 28 minutes, that is 8.2 utterances per minute The sample showed no difference between men and women in the amount spoken Utterances in the form of orders – an average of 25.4 per scenario – account for almost a tenth of all utterances There were 31.3 questions asked per scenario In terms of content, it should be considered that the proportion of genuine questions is much lower, because many directives are clothed in the form of a question (‘Would you hold the bag?’) Table 18.5 shows the distribution of these formal categories in the scenarios

The formal categories showed no significant differences between the scenarios, sexes, or experience – nor any interaction between the factors This finding is surprising, because it seems to mean that anaesthesiologists in the simulator

•

•

•

•

•

•

Acute phase 1 (pneumoperitoneum

with circulatory reaction)

Acute phase 2 (discr venous bleeding)

Acute phase 3 (air embolism)

Anaesthesia

introduced

(0–2Pt)

Differential

diagnose

(0–2Pt)

Therapy (0–2Pt)

Therapy (0–2Pt)

Diag

standard (0–2Pt)

Diag

advanced (0–2Pt)

Therapy circulation (0–2Pt)

Therapy breathing (0–2Pt)

Table 18.4 items for evaluating medical management (Scenario 1)

utter a certain number of utterances of a specific kind This should be further investigated

Proportion of Utterances Aiming at Team Coordination and the Establishment of

a Shared Mental Model

How much of what is said relates to the coordination of team activity and the establishment of shared mental models? Here we looked at the categories:

conveying information; thinking out loud; conveying problems (facts only); conveying problems with an explanation or model; explanation of one’s own activity; redundance; confirming understanding; addressing the surgeon (anaesthesiologist’s initiative).

An essential factor in successful problem solving is establishing shared mental models This process cannot be completely observed, but there are utterances that explicitly suggest the intention of improving a shared mental

model (e.g., confirming understanding; explanation of one’s own activity) and some that can help the other team members in ‘pacing’ (e.g., thinking aloud; conveying information) The importance of these tasks for problem solving

is reflected in the frequency of such utterances: the anaesthesiologist says something that can contribute to team coordination a mean of 108 times per scenario, almost four times per minute This corresponds, in the mean, to almost half of all utterances (47 percent) But a mean of only 18 utterances were

explicitly related to establishing shared mental models (conveying problems with explanation; explanation of one’s own activity; confirming understanding)

Table 18.6 shows the distribution among categories that we regard as helpful

in or as aiming directly at constructing shared mental models As with the categories of action organization, there are enormous individual differences

The frequency of redundance seems to indicate the anaesthesiologist’s intense

safety awareness

In these categories, we found there are no differences in relation to experience

or sex

order Statement/ utterance Other/ filler

phrases

Utterances total

Table 18.5 Formal characteristics of utterances in the scenarios

Utterances Concerning the Team and the Team Problem-solving Process

How much of what is said relates to the team and the process of working together?

We counted the categories: reflection or emotional utterance; references to relationships; process.

A large part of the speaking is devoted to coordinating activity (especially with the nurse); but very few utterances are directly related to the team In the scenarios, only the relationship to the surgeon was thematized, usually to draw boundaries (in the sense of ‘Don’t interfere with my work, I don’t try to tell you what to do, either’), seldom to underscore the shared team task (e.g., ‘Now

we have to manage this together’) Reflection on the problem-solving process was bundled together with utterances of one’s own emotional state (e.g., ‘Here I’m not so sure, either…’), because we expected (and found) few self-reflective utterances in the sense of strategy evaluation Utterances related to the work process (‘Let’s do this now one step at a time’) accounted for a mean proportion

of 5 percent; this is less than one would expect for ‘good team achievement’ (see Table 18.7)

Interestingly, there was virtually no communication about goals or plans (less than 1 percent of all utterances) This may be due to the pressure of the situation,

or it could indicate a learning need for team problem solving The individual differences are substantial in the categories of team and problem-solving process, but women and men do not significantly differ in their use of these categories

(p=.360, t=.93; df=32) Nor do experience or the scenario type lead to significant differences in these categories (F=2.04; p=.15; and F=0.17; p=.84).

Table 18.6 utterances related to team coordination and shared mental

models