Sarah Whyte

Communication failures in the operating room: an observational classification of recurrent types and effects

Background: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. Methods: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. Results: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included “occasion” (45.7% of instances) where timing was poor; “content” (35.7%) where information was missing or inaccurate, “purpose” (24.0%) where issues were not resolved, and “audience” (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. Conclusion: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.

Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR

Background: Pilot studies of complex interventions such as a team checklist are an essential precursor to evaluating how these interventions affect quality and safety of care. We conducted a pilot implementation of a preoperative team communication checklist. The objectives of the study were to assess the feasibility of the checklist (that is, team members’ willingness and ability to incorporate it into their work processes); to describe how the checklist tool was used by operating room (OR) teams; and to describe perceived functions of the checklist discussions. Methods: A checklist prototype was developed and OR team members were asked to implement it before 18 surgical procedures. A research assistant was present to prompt the participants, if necessary, to initiate each checklist discussion. Trained observers recorded ethnographic field notes and 11 brief feedback interviews were conducted. Observation and interview data were analyzed for trends. Results: The checklist was implemented by the OR team in all 18 study cases. The rate of team participation was 100% (33 vascular surgery team members). The checklist discussions lasted 1–6 minutes (mean 3.5) and most commonly took place in the OR before the patient’s arrival. Perceived functions of the checklist discussions included provision of detailed case related information, confirmation of details, articulation of concerns or ambiguities, team building, education, and decision making. Participants consistently valued the checklist discussions. The most significant barrier to undertaking the team checklist was variability in team members’ preoperative workflow patterns, which sometimes presented a challenge to bringing the entire team together. Conclusions: The preoperative team checklist shows promise as a feasible and efficient tool that promotes information exchange and team cohesion. Further research is needed to determine the sustainability and generalizability of the checklist intervention, to fully integrate the checklist routine into workflow patterns, and to measure its impact on patient safety.

Silence, Power and Communication in the Operating Room

Title. Silence, power and communication in the operating room Aim This paper is a report of a study conducted to explore whether a 1- to 3-minute preoperative interprofessional team briefing with a structured checklist was an effective way to support communication in the operating room. Background Previous research suggests that nurses often feel constrained in their ability to communicate with physicians. Previous research on silence and power suggests that silence is not only a reflection of powerlessness or passivity, and that silence and speech are not opposites, but closely interrelated. Methods We conducted a retrospective study of silences observed in communication between nurses and surgeons in a multi-site observational study of interprofessional communication in the operating room. Over 700 surgical procedures were observed from 2005–2007. Instances of communication characterized by unresolved or unarticulated issues were identified in field notes and analysed from a critical ethnography perspective. Findings We identified three forms of recurring ‘silences’: absence of communication; not responding to queries or requests; and speaking quietly. These silences may be defensive or strategic, and they may be influenced by larger institutional and structural power dynamics as well as by the immediate situational context. Conclusions There is no single answer to the question of why ‘nobody said anything’. Exploring silences in relation to power suggests that there are multiple and complex ways that constrained communication is produced in the operating room, which are essential to understand in order to improve interprofessional communication and collaboration.

Junior faculty experiences with informal mentoring.

Mentoring is one way in which new faculty can acquire the skills needed for a successful academic career. Little is known about how informal mentoring is operationalized in an academic setting. This study had two main objectives: (1) to determine if junior faculty identify as having an informal mentor(s) and to describe their informal mentoring relationships; and (2) to identify the areas in which these faculty seek career assistance and advice. The study employed a grounded theory approach. Subjects were recruited from the clinical teaching faculty and were 3–7 years into their first faculty position. Theoretical sampling was employed in which data analysis proceeded along-side data collection, and collection ceased when saturation of themes was reached. Saturation was reached at ten subjects. Data were collected by individual interviews. Four topics recurred: qualities sought in mentors, processes by which guidance is obtained, content of the guidance received and barriers. Faculty obtained guidance in two principal ways: (a) through collegial working relationships; and (b) through discussion with senior clinicians as part of the evaluative system in the department. Participants discussed the degree of mentoring they received in the areas of: career focus, orientation to the organization, transition of role from trainee to faculty and work/nonwork balance. Barriers identified included an evaluative role and conflict of interest on the mentors part. Junior faculty identify some relationships from which they receive guidance; however, limitations in these relationships result in a lack of mentorship on career direction and on balancing career with personal life.

A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability

Background: Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events. Aim: To describe the process of developing an authentic, theory-based evaluation instrument that measures communication among members of the operating room team by documenting communication failures. Methods: 25 procedures were viewed by 3 observers observing in pairs, and records of events on each communication failure observed were independently completed by each observer. Each record included the type and outcome of the failure (both selected from a checklist of options), as well as the time of occurrence and a description of the event. For each observer, records of events were compiled to create a profile for the procedure. Results: At the level of identifying events in the procedure, mean inter-rater agreement was low (mean agreement across pairs 47.3%). However, inter-rater reliability regarding the total number of communication failures per procedure was reasonable (mean ICC across pairs 0.72). When observers recorded the same event, a strong concordance about the type of communication failure represented by the event was found. Discussion: Reasonable inter-rater reliability was shown by the instrument in assessing the relative rate of communication failures displayed per procedure. The difficulties in identifying and interpreting individual communication events reflect the delicate balance between increased subtlety and increased error. Complex team communication does not readily reduce to mere observation of events; some level of interpretation is required to meaningfully account for communicative exchanges. Although such observer interpretation improves the subtlety and validity of the instrument, it necessarily introduces error, reducing reliability. Although we continue to work towards increasing the instrument’s sensitivity at the level of individual categories, this study suggests that the instrument could be used to measure the effect of team communication intervention on overall failure rates at the level of procedure.

Paradoxical effects of interprofessional briefings on OR team performance

Our recent research has found that structured preoperative team briefings can reduce communication failures, improve the knowledge and practice of operating room (OR) team members, and garner broad support from surgeons, nurses, and anesthesiologists. However, we have also encountered challenges and unexpected, negative effects. Using qualitative analysis of fieldnotes from 302 preoperative team briefings, we identified five paradoxical findings: team briefings could mask knowledge gaps, disrupt positive communication, reinforce professional divisions, create tension, and perpetuate a problematic culture. Fifteen percent of the briefings exhibited only these paradoxical effects without any apparent utility. We describe these paradoxical findings and analyze them in relation to educational, functional, structural, and cultural factors. This analysis is instructive not only for re-engineering the briefing process, but also for revealing dynamics that may continue to impede optimal interprofessional performance.

Questioning context: a set of interdisciplinary questions for investigating contextual factors affecting health decision making

Objective  To combine insights from multiple disciplines into a set of questions that can be used to investigate contextual factors affecting health decision making.

Misalignments of Purpose and Power in an Early Canadian Interprofessional Education Initiative.

Interprofessional education (IPE) has been widely incorporated into health professional curricula and accreditation standards despite an arguably thin base of evidence regarding its clinical effects, theoretical underpinnings, and social implications. To better understand how and why IPE first took root, but failed to grow, this study examines one of the earliest documented IPE initiatives, which took place at the University of British Columbia between 1960 and 1975. We examined a subset of 110 texts (academic literature, grey literature, and unpublished records) from a larger study that uses Critical Discourse Analysis to trace the emergence of IPE in Canada. We asked how IPE was promoted and received, by whom, for what purposes, and to what effects. Our analysis demonstrates that IPE was promoted as a response to local challenges for the Faculty of Medicine as well as national challenges for Canada’s emerging public healthcare system. These dual exigencies enabled the IPE initiative, but they shaped it in somewhat divergent ways: the former gave rise to its core component (a health sciences centre) and the latter its ultimate purpose (increasing the role of non-medical professions in primary care). Reception of the initiative was complicated by a further tension: nurses and allied health professionals were sometimes represented as independent experts with unique knowledge and skills, and sometimes as assistants or substitutes for medical doctors. We relate the successes and frustrations of this early initiative to particular (mis)alignments of purpose and relationships of power, some of which continue to enable and constrain IPE today.