Sherry Espin

Team Communications in the Operating Room: Talk Patterns, Sites of Tension, and Implications for Novices

Purpose Although the communication that occurs within health care teams is important to both team function and the socialization of novices, the nature of team communication and its educational influence are not well documented. This study explored the nature of communications among operating room (OR) team members from surgery, nursing, and anesthesia to identify common communicative patterns, sites of tension, and their impact on novices. Method Paired researchers observed 128 hours of OR interactions during 35 procedures from four surgical divisions at one teaching hospital. Brief, unstructured interviews were conducted following each observation. Field notes were independently read by each researcher and coded for emergent themes in the grounded theory tradition. Coding consensus was achieved via regular discussion. Findings were returned to insider “experts” for their assessment of authenticity and adequacy. Results Patterns of communication were complex and socially motivated. Dominant themes were time, safety and sterility, resources, roles, and situation. Communicative tension arose regularly in relation to these themes. Each procedure had one to four “higher-tension” events, which often had a ripple effect, spreading tension to other participants and contexts. Surgical trainees responded to tension by withdrawing from the communication or mimicking the senior staff surgeon. Both responses had negative implications for their own team relations. Conclusions Team communications in the OR follow observable patterns and are influenced by recurrent themes that suggest sites of team tension. Tension in team communication affects novices, who respond with behaviors that may intensify rather than resolve interprofessional conflict.

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.

Pulling Together and Pushing Apart: Tides of Tension in the ICU Team

Balancing interdisciplinary differences and coping with the strain of limited resources, intensive care unit (ICU) teams face the physical and psychological stress of caring for the critically ill. Differences in knowledge and skill, gender, and care models are organized by a complex hierarchical structure that does not always adequately account for these differences. Thus, ICU teams not only face the challenge of working efficiently in a highly stressful acute care environment, they also confront the complexities of interprofessional communication and collaboration. Multifaceted interprofessional relationships must be established and re-established as individual providers continuously rotate to and from the unit. These characteristics provide the context for potentially divisive team communication and pose significant challenges to team collaboration. Problems in team communication and collaboration may have significant impact on administrative, social, clinical, and educational outcomes in the ICU. Previous studies have highlighted the importance of collaboration in improving patient outcomes, in decision making around ethical issues and in improving the team’s morale. Other studies have focused on physician–nurse interactions and describe inadequate communication of treatment goals and a lack of collaboration, as well as a lack of understanding and frank disputes over roles and responsibilities. This study examines communication patterns in the context of this continuously shifting interprofessional team. Further, it explores the implications of these patterns for the education and socialization of critical care trainees as they negotiate professional roles and relationships within the hidden curriculum of critical care medicine.

Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice

Background Suboptimal communication within healthcare teams can lead to adverse patient outcomes. Team briefings were previously associated with improved communication patterns, and we assessed the impact of briefings on clinical practice. To quantify the impact of the preoperative team briefing on direct patient care, we studied the timing of preoperative antibiotic administration as compared to accepted treatment guidelines. Study design A retrospective pre-intervention/post-intervention study design assessed the impact of a checklist-guided preoperative team briefing on prophylactic antibiotic administration timing in surgical cases (N=340 pre-intervention and N=340 post-intervention) across three institutions. χ2 Analyses were performed to determine whether there was a significant difference in timely antibiotic administration between the study phases. Results The process of collecting and analysing these data proved to be more complicated than expected due to great variability in documentation practices, both between study sites and between individual practitioners. In cases where the timing of antibiotics administration was documented unambiguously in the chart (n=259 pre-intervention and n=283 post-intervention), antibiotic prophylaxis was on time for 77.6% of cases in the pre-intervention phase of the study, and for 87.6% of cases in the post-intervention phase (p<0.01). Conclusions Use of a preoperative team checklist briefing was associated with improved physician compliance with antibiotic administration guidelines. Based on the results, recommendations to enhance timely antibiotic therapy are provided.

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.

Teaching operating room conflict management to surgeons: clarifying the optimal approach

Medical Education 2011:45: 939–945

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.

An interprofessional education pilot program in maternity care: Findings from an exploratory case study of undergraduate students

An interprofessional team of maternity care providers and academics developed a pilot interprofessional education (IPE) program in maternity care for undergraduate students in nursing, midwifery and medicine. There are few published studies examining IPE programs in maternity care, particularly at the undergraduate level, that examine long-term outcomes. This paper outlines findings from a case study that explored how participation in an IPE program in maternity care may enhance student knowledge, skills/attitudes, and may promote their collaborative behavior in the practice setting. The program was launched at a Canadian urban teaching hospital and consisted of six workshops and two clinical shadowing experiences. Twenty-five semi-structured, in-depth interviews were completed with nine participants at various time points up to 20 months post-program. Qualitative analysis of transcripts revealed the emergence of four themes: relationship-building, confident communication, willingness to collaborate and woman/family-centered care. Participant statements about their intentions to continue practicing interprofessional collaboration more than a year post-program lend support to its sustained effectiveness. The provision of a safe learning environment, the use of small group learning techniques with mixed teaching strategies, augmented by exposure to an interprofessional faculty, contributed to the programs perceived success.

Surgeons managing conflict in the operating room: defining the educational need and identifying effective behaviors

BACKGROUND Developing an operating room conflict management educational program for surgeons requires a formal needs assessment and information about behaviors that represent effective conflict management. METHODS Focus groups of circulating room nurses and surgeons were conducted at 5 participating centers. Participants responded to queries about conflict management training, conflict consequences, and effective conflict management behaviors. Transcripts of these sessions served as the data for this study. RESULTS Educational preparation for conflict management was inadequate consisting of trial and error with observed behaviors. Conflict and conflict mismanagement had negative consequences for team members and team performance. Four behaviors emerge as representing effective ways for surgeons to manage conflict. CONCLUSIONS There is a clear educational need for conflict management education. Target behaviors have now been identified that can provide the basis for a theoretically grounded and contextually adapted instruction and assessment of surgeon conflict management.

Exploring interprofessional collaboration during the integration of diabetes teams into primary care

BackgroundSpecialised diabetes teams, specifically certified nurse and dietitian diabetes educator teams, are being integrated part-time into primary care to provide better care and support for Canadians living with diabetes.This practice model is being implemented throughout Canada in an effort to increase patient access to diabetes education, self-management training, and support. Interprofessional collaboration can have positive effects on both health processes and patient health outcomes, but few studies have explored how health professionals are introduced to and transition into this kind of interprofessional work.MethodData from 18 interviews with diabetes educators, 16 primary care physicians, 23 educators’ reflective journals, and 10 quarterly debriefing sessions were coded and analysed using a directed content analysis approach, facilitated by NVIVO software.ResultsFour major themes emerged related to challenges faced, strategies adopted, and benefits observed during this transition into interprofessional collaboration between diabetes educators and primary care physicians: (a) negotiating space, place, and role; (b) fostering working relationships; (c) performing collectively; and (d) enhancing knowledge exchange.ConclusionsOur findings provide insight into how healthcare professionals who have not traditionally worked together in primary care are collaborating to integrate health services essential for diabetes management. Based on the experiences and personal reflections of participants, establishing new ways of working requires negotiating space and place to practice, role clarification, and frequent and effective modes of formal and informal communication to nurture the development of trust and mutual respect, which are vital to success.