Jon Allard

The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors.

Medical Education 2010: 44: 449–458

Improving teamwork climate in operating theatres:The shift from multiprofessionalismto interprofessionalism

A multi-faceted, longitudinal and prospective collaborative inquiry was initiated in December 2002 with one half of the cohort of operating theatre personnel in a large, acute UK hospital serving a mainly rural population. The same intervention was introduced in January 2004 to the other half of the cohort. The project aims to improve patient safety through a structured educational intervention focussed upon changing teamwork practices. This article reports one critical element of the larger project – changing teamwork climate as a necessary precursor to establishing an interprofessional teamwork culture. The aggregate of individual, unidirectional attitude changes across a large cohort constitutes a change in climate. This shift challenges the conventional culture of multiprofessionalism, where uniprofessional identification (the “silo” mentality) is traditionally strong.

Pre-surgery briefings and safety climate in the operating theatre

Background In 2008, the WHO produced a surgical safety checklist against a background of a poor patient safety record in operating theatres. Formal team briefings are now standard practice in high-risk settings such as the aviation industry and improve safety, but are resisted in surgery. Research evidence is needed to persuade the surgical workforce to adopt safety procedures such as briefings. Objective To investigate whether exposure to pre-surgery briefings is related to perception of safety climate. Methods Three Safety Attitude Questionnaires, completed by operating theatre staff in 2003, 2004 and 2006, were used to evaluate the effects of an educational intervention introducing pre-surgery briefings. Results Individual practitioners who agree with the statement ‘briefings are common in the operating theatre’ also report a better ‘safety climate’ in operating theatres. Conclusions The study reports a powerful link between briefing practices and attitudes towards safety. Findings build on previous work by reporting on the relationship between briefings and safety climate within a 4-year period. Briefings, however, remain difficult to establish in local contexts without appropriate team-based patient safety education. Success in establishing a safety culture, with associated practices, may depend on first establishing unidirectional, positive change in attitudes to create a safety climate.

“Who's on the team today?” The status of briefing amongst operating theatre practitioners in one UK hospital

Accidents in health care are mainly due to systemic communication errors. Errors occur more frequently in the operating theatre (OT) than other clinical settings. Hence, it is important that preventive communication practices are adopted in OT teams. Formal team pre-briefing has been shown to improve safety in high risk settings such as aviation, but such briefing is not common practice in OT teams. This paper reviews key literature demonstrating the value of briefing in high-risk practices; presents and analyses the results of a questionnaire survey on the status of briefing after its introduction to OT teams in one UK hospital; and analyses processes that frustrate widespread adoption of briefing. In comparison with other OT practitioners, surgeons generally reported differing perceptions of the meaning and value of briefing, often holding broad notions of what constitutes a “brief”, but also showing scepticism towards briefing. However, surgeons who had introduced briefing reported positive results such as greater efficiency, shared understanding, and increased team morale. Collaborative briefing that extends beyond the technical to include the interpersonal could be initiated in principle by any member of the OT team, but a number of factors inhibit this, and surgeons play a pivotal role in establishing briefing.

Towards culture change in the operating theatre: Embedding a complex educational intervention to improve teamwork climate

Background: Changing teamwork climate in healthcare through a collective shift in attitudes and values may be a necessary precursor to establishing a positive teamwork culture, where innovations can be more readily embedded and sustained. A complex educational intervention was initiated across an entire UK Trusts surgical provision, and then sustained. Attitudes towards teamwork were measured longitudinally to examine if the intervention produced sustainable results. Aims: The research aimed to test whether sustaining a complex education intervention to improve teamwork would result in an incremental, longitudinal improvement in attitudes and values towards teamwork. The interventions larger aim is to progress the historical default position of multi-professional work to authentic inter-professional teamwork, as a positive values climate translates in time into behavioural change defining a safety culture. Method: Attitudes were measured at three points across all surgical team personnel over a period of 4 years, using a validated Safety Attitudes Questionnaire with a focus on the ‘teamwork climate’ domain. Pre- and post-intervention ‘teamwork climate’ scores were compared to give a longitudinal measure as a test of sustainability. Results: Mean ‘teamwork climate’ scores improved incrementally and significantly following the series of educational interventions, showing that practitioners’ valuing of teamwork activity can be improved and sustained. Conclusions: Longitudinal positive change in attitudes and values towards teamwork can be sustained, suggesting that a deliberate, designed complex intervention can shape a safety climate as a necessary prerequisite for the establishment of a sustainable safety culture.

Do you really need to ask me that now?: a self-audit of interruptions to the 'shop floor' practice of a UK consultant emergency physician.

Objectives To map interruptions encountered by a senior physician performing a variety of everyday tasks on an emergency department (ED) ‘shop floor’ in the UK in order to identify tasks most likely to be interrupted, modes of interruption and those interruptions most likely to result in breaks as suspension of the original task. Methods A self-observational audit study of interruptions was undertaken by a consultant emergency physician in a medium-sized ED over 25 separate shifts totalling 119 h. The main outcome measures were type and occurrence of interruption in relation to mode of original task. ‘Success’ of interruptions and number of outstanding tasks were also recorded. Results 718 interruptions were recorded, with an average of 6 per hour. A mean number of 2.44 outstanding tasks were recorded on each occasion of interruption. Verbal advice, telephone calls and interpretations of x-rays were the most common forms of interruption. 498 interruptions (69%) were successful, defined as interruptions that resulted in a task break (over-riding and suspension of the original task). The most successful interruptions were calls to the resuscitation room (95%). Interruptions from electronic telecommunications systems were extensive (33% of total) with success dependent on the type of communication system. Telephone conversations were rarely interrupted (16% compared with a mean of 69%). Conclusions Overt electronic communication systems may have a disproportionate impact in determining the likelihood for successful interruptions. Formal consideration of how to prioritise and manage interruptions from various channels could be usefully added to emergency medicine education and training.

What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings

Top-down policy directives, such as targets and their associated protocols, may be driven politically rather than clinically and can be described as macro-political texts. While targets supposedly provide incentives for healthcare services, they may unintentionally shape practices of accommodation rather than implementation, deflecting practitioners from providing optimal care. Live work activities were observed for two six months periods in a UK NHS Emergency Department and a Mental Health Ward using video and field notes ethnography, with post hoc unstructured interviews for clarification and verification. Sixty-four practitioners were consented. Data were treated as narratives, analysed thematically and theorised using cultural–historical activity theory. The ideal text of patient-centred team working shaped by top-down, politically inspired targets was disrupted, where targets produced unintended consequences. Bottom-up strategies of making meaning of targets in a local context generated sub-texts of resistance, rationalization, and even duplicity that had paradoxical positive effects in generating collaboration and democratic habits. Throughput pressures generated both cross-team conflicts and intra-team identification. What practitioners actually do to make sense of top-down directives is not the same as the ideal expectation framed by targets. Team members pulled together not because of targets but in spite of them, and as a form of resistance to governance. Targets produce unnecessary stress as team members focus on throughput rather than quality of care. Those governing healthcare must look at the unintended consequences of targets.

The transition from medical student to junior doctor: today's experiences of Tomorrow's Doctors

Medical Education 2010: 44: 449–458

The transition from medical student to junior doctor

Medical Education 2010: 44: 449–458