Safer Surgery 234 in anaesthesia crews in clinical and simulated work environments. Furthermore, we were able to establish a relationship between certain coordination patterns and clinical performance ratings for a specic anaesthetic crisis in a simulator scenario. In a current project (see also Chapter 13 by Kolbe et al. in this book), we continue the task-analytic approach to adaptive coordination in anaesthesia crews. This research aims at improving instruments and procedures for team performance assessment by comparing and potentially integrating two observation systems for coordination behaviour. The focus of this project is to empirically evaluate the predictive power of two different observation systems for coordination processes with regard to non-technical skills and clinical performance assessments. Because many assessments of healthcare professionals’ work, especially in critical situations, are only possible in a simulator environment, we continue a research strategy using both clinical and simulated research settings to best develop the strengths and counter the limitations associated with either setting. The results of this study will provide an important contribution to improving systems used to assess coordination as a central aspect of team performance. If team performance cannot be assessed accurately, efforts to dene specic training needs and to improve team performance may be futile (Manser 2008). In order to dene specic competencies that team training should address, to monitor progress, and to nally assess competence, research needs to establish a link between specic behaviours and patient outcome. Acknowledgements This research was funded by the Swiss National Science Foundation (PBZH1- 100994). 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Proceedings of the Human Factors and Ergonomics Society 42nd annual meeting (pp. 186–90). Santa Monica: Human Factors and Ergonomics Society. Young, G.J., Charns, M.P., Desai, K., Khuri, S.F., Forbes, M.G., Henderson, W., et al. (1998) Patterns of coordination and clinical outcomes: A study of surgical services. Health Services Research 33(5 Pt 1), 1211–36. Yule, S., Flin, R., Paterson-Brown, S., Maran, N. and Rowley, D. (2006) Development of a rating system for surgeons’ non-technical skills. Medical Education 40(11), 1098–104. This page has been left blank intentionally Chapter 15 Teams, Talk and Transitions in Anaesthetic Practice Andrew Smith, Catherine Pope, Dawn Goodwin and Maggie Mort Introduction Effective communication skills are required for the practice of anaesthesia as they are for any branch of clinical medicine. Despite their importance in practice (Kopp and Shafer 2000, Smith and Shelly 1999) and training (Harms et al. 2004), published work tends to deal with formal, explicit teaching of specic skills such as patient handover (Solet et al. 2005). Communication with patients takes place preoperatively when the anaesthesiologist rst meets the patient, on induction of anaesthesia, during surgery (if the patient is conscious), on emergence from anaesthesia and again with the patient postoperatively. Communication also takes place between members of the anaesthetic team – by which we mean anaesthesiologists, their assistants and the recovery room staff. What anaesthesiologists say at these points has seldom been formally studied, and does not feature in traditional textbook teaching on anaesthesia, but seems instead to be learned as part of the informal ‘unofcial syllabus’ of anaesthetic knowledge (Smith 2007). Further, the issue of how communication is shared between anaesthesiologists and other members of the anaesthetic team does not appear to have been explored. In this chapter we will present data from the Lancaster anaesthetic expertise study, looking at communication between members of the anaesthesia team at a number of transition points: induction of anaesthesia, emergence from anaesthesia and handover of the patient in the recovery room. Methods The approval of the local research ethics committees was granted for this study, and written informed consent obtained from patients being cared for by the anaesthesiologists under observation. The study was conducted principally in a medium-sized district hospital in the north-west of England, with shorter periods of observation at a university hospital in the south-west of England. We adopted an ethnographic approach, grounded in detailed observation (Atkinson et al. 2001), followed by a series of in-depth interviews. Ethnography is often used for the in-depth study of complex phenomena within the social context they occur and, Safer Surgery 242 as in this study, typically combines a range of methods including observation, interviews and documentary analysis (Pope 2005, Savage 2000). The Lancaster study aimed to explore the ways different types of knowledge are acquired and used in anaesthetic practice. It focused mainly on the operating theatre environment, and included observation of and interviews with anaesthesiologists, operating department practitioners (ODPs) 1 and nurses working in the operating theatre and recovery room (Pope et al. 2003, Smith et al. 2003a). Operating sessions were purposively sampled to cover a range of different types of surgery and anaesthetic practice and levels of anaesthetic expertise. Most commonly, an individual anaesthesiologist was observed during the course of a routine operating theatre session. We also focused on physical areas, such as the recovery room, and on operating lists where trainer–trainee interactions were taking place. All anaesthesiologists and operating theatre staff were aware of the study. The anaesthesiologists taking part all had the opportunity to decline to be involved either in the study as a whole or in individual observation. The researcher would obtain consent before each observation session. Typically, observation started in the anaesthetic room before the patient arrived and, in some but not all cases, continued until after the patient had been transferred to the recovery room. Conversation between all those in the anaesthetic room – patients, members of the anaesthesia team, surgeons and others who entered the room during this time – was recorded in the form of near-verbatim notes. Observation further continued to include emergence from anaesthesia and then the handover to the recovery room nurse. The researchers recorded, with note book and pencil, the events, talk and behaviour of the anaesthesiologists and other anaesthesia personnel. They aimed to capture the complexity of anaesthesia practice. Immediately after the observation session, these were expanded and annotated, then transcribed for analysis. The interviews we conducted were carried out on a purposively selected cross-section of anaesthesia personnel – physicians, nurses and ODPs. The analysis was directed towards classifying the communication which occurred at induction, emergence and handover and began with individual close readings and annotations of the observational transcripts by all members of the project team, looking for recurring patterns of talk, behaviour and interaction. These were subsumed into broader categories and themes (Silverman 2001). Discordant data – instances where observed or reported communication differed from the norm or was deemed to be inappropriate in some way – were noted and discussed in detail. Such cases usually stand out in the analysis as they appear contradict the emerging explanation of the phenomena under study and they therefore help to rene the analysis by focussing attention on aspects of the 1 The operating department practitioner is a grade of theatre staff unique to the UK. Their two/three-year training course prepares them for three aspects of theatre work: assisting the surgeon, assisting the anaesthesiologist and working in the theatre recovery room. Teams, Talk and Transitions 243 data which might otherwise have gone unnoticed. Differences in communication between expert and inexperienced practitioners were deliberately sought and examined. These can be especially valuable when a phenomenon such as tacit knowledge in anaesthesia is being studied, as this knowledge may be more easily visible when it is poorly developed or still being formed, as in the observation of trainees at work. The aim of ethnographic research is to produce an account of what is being observed that makes sense to the participants being studied – to get ‘under the skin’ of what is going on (Pope 2005) and to develop concepts or analytical categories that can be applied to other settings, rather than to produce statistical generalizations. Typically such studies have smaller samples (Silverman 2001, Pope et al. 2000) and a judgement is made that sufcient data have been collected when further analysis of new data yields no new categories or emerging themes (‘data saturation’: Miles and Huberman 1994). To check the accuracy of our interpretations and ndings, some of the research participants were invited to examine the analysis and to tell us if the picture we presented of anaesthetic practice reected their own experiences and understandings. Results Approximately three observation periods were carried out per month over one year, yielding a total of 39 sessions comprising 133 hours of data. At the time we made our observations, there were 12 consultant anaesthesiologists in the department and ten trainees. We observed all but one of the consultants at least once. Of the 31 observations in the operating theatres at the primary site, 13 were of consultants working alone, 12 were a consultant/trainee pair and 6 were of trainees working alone. Nineteen interviews were conducted (Smith et al. 2003a) with anaesthesiologists, anaesthetic and recovery nurses. These interview data were used to supplement and cross-reference the ndings from the workplace observation, which was the main focus of our inquiry. The study as a whole illuminated, for the rst time, the interplay of different types of knowledge in professional anaesthetic practice, and how such knowledge is acquired and used. Apart from the general aspects of anaesthetic expertise, we have also been able to draw out more specic aspects of expertise in relation to the use of electronic monitoring (Smith et al. 2003b), regional anaesthesia (Smith et al. 2006a) and the denition and reporting of critical incidents (Smith et al. 2006b), as well as enlightening the sociological discourses of human–machine interaction and distribution of work in interprofessional settings (Goodwin et al. 2005, Mort et al. 2005). For the purpose of this chapter, we focus on observations of the induction of general anaesthesia on 54 occasions, and of 31 patients emerging from anaesthesia. (The imbalance here arose from the fact that the observers were primarily following the anaesthesiologist, and many patients had been handed over to recovery room personnel before emergence (waking up) from the anaesthetic (Smith et al. 2005)). . within the social context they occur and, Safer Surgery 242 as in this study, typically combines a range of methods including observation, interviews and documentary analysis (Pope 2005, Savage. and Reason, J.T. (2001) The human factor in cardiac surgery: Errors and near misses in a high technology medical domain. Annals of Thoracic Surgery 72(1), 300–305. Chassin, M.R. and Becher, E.C anaesthesia: A review of current literature. British Journal of Anaesthesia 88(3), 418–29. Safer Surgery 236 Fletcher, G., Flin, R., McGeorge, P., Glavin, R.J., Maran, N. and Patey, R. (2004)