Safer Surgery part 33 potx

Safer Surgery 294 questions (Can you manually adjust white balance? Let’s try again. Can you adjust the colour?). The circulating nurse hears and acts on these questions but never articulates or announces her actions. She eventually goes to call for help; this time she announces that she has called. The OR-coordinator arrives and then the PSA. OR-coordinator leaves. PSA arrives, [ddles] with controls for a while (though it seems he doesn’t have any solutions). The staff surgeon nally asks again: ‘Are we getting another tower?’ The circulating nurse pages a second PSA, returns and asks this PSA if there’s another in the ofce. The circulating nurse disappears without indicating that she’s going. Second PSA arrives and mumbles about being in six rooms, can’t hear the pages. The staff surgeon asks the rst PSA about the resolution. PSA1 says they can bring another or turn this one off and on again. They try turning off and on, with no success. Third screen arrives (a second was rolled in earlier but nobody pointed it out). PSA1 and the circulating nurse (who is now back in the room) set up new screen at 11:30am. Observer notes: This seems to be primarily a style problem. Neither staff surgeon nor (especially) circulating nurse speaks very assertively in naming and navigating the situation. There seems to be less communication than needed for efcient resolution of the problem. I’ve also recorded this as a ‘content’ failure to capture that element of the exchange. Relevant information seems lacking (for example, status of attempt to x the problem, plan to x the problem, opinions about what should be done). As this observer notes, the silences in this communication exchange seem attributable to personal ‘style’: some team members are more ‘quiet’ than others. In fact, volume and degree of communicative involvement – particularly the consistent patterning of who speaks more loudly and who speaks more quietly in the OR – is a function of social structures and power relationships, not only an issue of personal preference. Degree of communicative involvement can be a cultural – as well as a personal – pattern. Survey research by Sexton et al. (2000) suggests that surgical culture discourages questioning and cross-checking across the team’s hierarchical layers, which can create an involvement where team members are more likely to speak when spoken to than to offer comments or questions. Examples in the eld notes suggest that this culture persists, particularly in instances where a volunteered question or comment reveals ignorance or mis-assumptions: As the surgeons close, the anaesthetist asks if they still have to do a stoma. The staff surgeon replies: ‘We’re not doing a stoma today doctor. We’re taking away the stoma. He came in with one and he’ s leaving without it.’ The anaesthetist’s question reveals his ignorance of the surgical procedure and wins him public ridicule, conrming that it would have been prudent to keep quiet. Medical sociological studies of uncertainty (Fox 1957, Lingard et al. 2002a) draw Counting Silence 295 attention to the tacit prohibitions against advertising what one does not know, and this cultural value likely shapes patterns of silence in an interprofessional and hierarchical environment such as the OR. A third pattern of silences emerges in the Content failures category: team exchanges in which barely concealed conict or anger simmers persistently but is never addressed. The following eld note excerpt illustrates the issue of silence and tacit conict: I think that the failures scale underestimated the communication problems for this case. There was a sense that the scrub nurse, the student scrub nurse, and the circulating nurse (this was a more novice circulating nurse; the senior circulating nurse from the preceding case was out of the room for much of this one) were not being effective at handing equipment or solving problems. I was aware of this, but the room remained quite quiet, and I was only able to document the issues in three failures. At the end of the procedure, the surgical fellow told me that she ‘was boiling inside’ for the whole case. ‘Usually they’re at least paying attention. Today, it was like, “Hello! We’re operating here”. I worry, based on the fellow’s comment, that my observational skills weren’t sharp enough today – but I also think that the surgeons internalized their frustration, so it was difcult to capture it through communication records. This example crystallizes the issue of tacit communication. Although the room was silent for much of the case, the observer could sense the conict and tension in the room, a sense conrmed by the fellow’s comments. Such lurking tensions can pose grave difculties for effective collaboration, yet they are difcult to capture in terms of a rating of explicit communication. Uncategorized Silences We have focused so far on the kinds of silences that our evaluative tool does manage to capture to some degree. While these examples illustrate the complexity of interpretation in assigning meanings to silence, another set of examples also require consideration: those for which our tool offers little or no basis for documentation. For example, in some observed cases there is no evidence on which to ascribe meaning to silence – just a description that there is no talk among team members: ‘The case proceeds uneventfully but there is no talk at all between professions before the case begins.’ Is this silence problematic? Certainly we have seen cases where such interprofessional silence is problematic, but we have also seen instances that suggest a team’s non-verbal uency. In one case, a nurse suggested pride in such silent team uidity, announcing cheerfully to the team, ‘Let’s see if we can do the whole case without talking’; in another case a surgeon noted to the observer, ‘Did you catch all of that non-verbal communication?’ Instances of complete silence present such ambiguity that we cannot condently Safer Surgery 296 assign them a category in our evaluative tool; therefore, if they are problematic, they are lost from the communication failures database. And, because our eld note descriptions of complete silence are so lean, we are equally unable to satisfactorily capture their productive functions. Summary and Implications Our approach to evaluating team communication is based on the premise of assessing communication within its social context, interpreting rather than eliding the richness of communicative events that emerge, overlap, evolve, echo, resolve, abort or die away. Within such complex discursive webs, we have faced the challenge of addressing the relationships between communicative presence and absence – between speech and silence. This chapter is a preliminary description of that challenge, not in an attempt to offer conclusions or gain closure, but rather to interrogate and open up this complexity in communicative performance data. This chapter foregrounds issues of interpretation rather than risking the perils of taking a literal approach to language: silences are meaningful but ambiguously so, and we have laid out our interpretive logic based on the rhetorical framework underpinning our evaluation tool. Our framework of audience, content, occasion and purpose is a way of categorizing communication failures that draws our attention to certain forms of communicative presence: an untimely instrument request, for instance, or a repeated question that rises in urgency. As we have described, in attending to the presence of such speech events, our attention is also drawn to the silences intertwined with them: the absence of an earlier, more proactive request or the absence of a response to the repeated question. In fact, our framework may impose a useful structure that helps render such silences ‘visible’ when they might otherwise escape observer’s evaluative attention, particularly in relation to two areas of our framework (purpose and content) where silences tend to recur. However, we acknowledge that other patterns of silence do not so readily surface within our framework, and further critical attention needs to be paid to delineating the interpretive challenges associated with these. The examples we consider illustrate that silence is neither straightforwardly ‘good’ nor straightforwardly ‘bad’. Silence can reect a lack of communication – an absence or gap in the chain of communication, such as when a request is not heard by a team member. But silence can also function as a communicative act that implies support, willingness to assist, inviting another to speak, keeping the peace, or pausing to reect. And it can function as the operationalization of power relations, such as when a team member is ‘silenced’ by another’s speech or the silence in the OR environment is oppressive, suggestive of unvoiced emotions running beneath the surface. Because silence is often a communicative act, an important part of team members’ communicative expertise is their ability to interpret and use silence. For instance, expert nurses possess a form of situation awareness that allows them Counting Silence 297 to distinguish the right moment to interrupt the surgeon’s silent concentration with questions. Similarly, decisions about what, when and how much to update on ‘in-progress’ issues likely involve a weighing of the desire for clarity and the prohibition against ‘cluttering up’ an already complex communicative environment with low-value messages such as ‘ultrasound hasn’t called back yet’. Understanding silence as more than communicative absence requires the assignment of meaning based on social and ecological cues: a complex but necessary endeavour if we are to achieve an authentic and ecologically valid assessment of communicative performance. As we account for silence in the evaluation of communication failures as an outcome in a team brieng intervention, there are two key interpretive dangers. We can underestimate communication failures by not accounting for silences at all or by misreading them as productive when they are not, or we can overestimate communication problems by misreading silences as problematic when they are not. Further, we can distort the distribution of failure types by forcing an assignment of meaning in a particular direction, such as interpreting all requests-without-responses as purpose failures when in fact silence may send a tacit message that resolves the question’s purpose. In our own work, we have used spontaneous interviews whenever possible to judge the meanings of silences for which contextual cues are ambiguous or lacking; however, this is not always a viable technique for performance assessment. Silence is intimately linked to speech in complex communicative environments like the operating room. While the evaluation of a team’s communicative performance traditionally focuses on what observers can see and objectively label, we need to pay attention to the interplay of speech and silence and articulate our logical frameworks for assigning meaning to silence. ‘Counting silence’ is a complicated but necessary business for performance evaluation for safer surgery: silence can promote safety when team members ‘count to ten’ and think before acting, and it can undermine safety when team members fail to cross-check and respond to one another’s questions. We hope that our reection on the patterns of silence as they emerge within the rhetorical framework of our evaluation tool will prompt surgical performance researchers to consider the problem of silence, towards carefully theorized and situated accounts of its role in teamwork. References Bradbury-Jones, C., Sambrook, S. and Irvine, F. (2007) Power and empowerment in nursing: A fourth theoretical approach. Journal of Advanced Nursing 62(2), 258–66. Brown, W. (2005) Freedom’s silences. In Edgework: Critical Essays on Knowledge and Politics (pp. 83–96). Princeton, NJ: Princeton University Press. Fox, R. (1957) Training for certainty. In R.K. Merton, G. Reader and P.L. Kendall (eds) The Student Physician. Cambridge, MA: Harvard University Press. Safer Surgery 298 Gillespie, B.M., Wallis, M. and Chaboyer, W. (2008) Operating theater culture: Implications for nurse retention. Western Journal of Nursing Research 30(2), 259–77. Glenn, C. (2004) Unspoken: A Rhetoric of Silence. Carbondale, IL: Southern Illinois University Press. Helmreich, R.L. (2000) On error management: Lessons from aviation. British Medical Journal 320(7237), 781–5. Helmreich, R.L. and Davies, J.M. (1994) Team performance in the operating room. In M.S. Bogner (ed.) Human Error in Medicine (pp. 225–53). Hillside, NJ: Erlbaum. Joint Commission on Accreditation of Healthcare Organizations (2003) Sentinel event statistics. 24 June. Available from: <http://www.jointcommission.org/ SentinelEvents/SentinelEventAlert/sea_29.htm> [last accessed March 2009]. Kohn, L.T., Corrigan, J.M., and Donaldson, M.S. (eds) (2000) To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press. Lingard, L., Espin, S., Rubin, B., Whyte, S., Colmenares, M., Baker, G.R., Doran, D., Grober, E., Orser, B., Bohnen, J. and Reznick, R. (2005) Getting teams to talk: Development and pilot implementation of a checklist to promote safer operating room communication. Quality and Safety in Health Care 14, 340–6. Lingard, L., Espin, S., Whyte, S., Regehr, G., Baker, R., Orser, B., Doran, D., Reznick, R., Bohnen, J. and Grober, E. (2004) Communication failures in the operating room: An observational classication of recurrent types and outcomes. Quality and Safety in Healthcare 13, 330–4. Lingard, L., Garwood, K., Schryer, C., and Spafford, M. (2002a) A certain art of uncertainty: Case presentation and the development of professional identity. Social Science and Medicine 56, 603–17. Lingard, L., Regehr, G., Orser, B., Reznick, R., Baker, G.R., Doran, D., Espin, S., Bohnen, J. and Whyte, S. (2008) Team talk: Preoperative briengs among surgeons, nurses and anesthetists reduce communication failures. Archives of Surgery 143(1), 12–17. Lingard, L., Regehr, G., Whyte, S., Reznick, R., Bohnen, J., Baker, G.R., Espin, S., Doran, D., Orser, B. and Grober, E. (2006) A theory-based instrument to evaluate team communication in the operating room: Balancing measurement authenticity and reliability. Quality and Safety in Health Care 15, 422–6. Lingard, L., Reznick, R., DeVito, I. and Espin, S. (2002b) Forming professional identities on the healthcare team: Discursive constructions of the ‘other’ in the operating room. Medical Education 36(8), 728–34. Lingard, L., Reznick, R., Espin, S., DeVito, I. and Regehr, G. (2002c) Team communication in the operating room: Talk patterns, sites of tension and implications for novices. Academic Medicine 77(3), 37–42. Manias, E. and Street, A. (2001) Nurse-doctor interactions during critical care ward rounds. Journal of Clinical Nursing 10, 442–50. Counting Silence 299 Riley, R. and Manias, E. (2005) Rethinking theatre in modern operating rooms. Nursing Inquiry 12, 2–9. Salas, E., Rosen, M.A., Burke, C.S., Nicholson, D. and Howse, W.R. (2007) Markers for enhancing team cognition in complex environments: The power of team performance diagnosis. Aviation Space and Environmental Medicine 78(5 Suppl), B77–85. Saville-Troike, M. (1985) The place of silence in an integrated theory of communication. In D. Tannen and M. Saville-Troike (eds) Perspectives on Silence. Norwood, NJ: Ablex Publishing Corporation. Saville-Troike, M. (2003) The Ethnography of Communication: An Introduction. 3rd edition. Malden, MA: Blackwell Publishing. Sexton, B.J., Thomas, E.J. and Helmreich, R.I. (2000) Error, stress and teamwork in medicine and aviation: Cross sectional surveys. British Medical Journal 320, 745–9. Tan, J., Naik, V. and Lingard, L. (2006) Exploring obstacles to proper timing of prophylactic antibiotics for surgical site infections. Quality and Safety in Health Care 15(1), 32–8. Undre, S., Sevdalis, N., Healey, A.N., Darzi, A. and Vincent, C.A. (2007) Observational Teamwork Assessment for Surgery (OTAS): Renement and application in urological surgery. World Journal of Surgery 31(7), 1373–81. This page has been left blank intentionally Chapter 18 Observing Team Problem Solving and Communication in Critical Incidents Gesine Honger and Cornelius Buerschaper Introduction Although a relatively recent research area, we are beginning to understand the signicance of human factors for patient safety, especially the role of interpersonal skills (e.g., Fletcher et al. 2003, Kohn et al. 1999) and the importance of non- technical skills on technical outcome factors (Mishra et al. 2008, Reader et al. 2006). Many efforts to improve non-technical skills have been made in different domains; for example the crew resource management training (CRM) in aviation, and adaptations in healthcare. CRM training was designed to strengthen team- related skills for decision-making in critical situations and to enhance safety during routine situations (Cannon-Bowers et al. 1995, Jensen 1995, Merrit and Helmreich 1997, Wiener et al. 1993). In unexpected situations, standard operating procedures (SOPs) do not help so then crews need to actively solve problems. Thus, the idea of CRM includes problem-solving and team skills or, rather, communication and teamwork are seen as means for good decision-making in the cockpit. One concept that combines communication, teamwork and problem solving is that of ‘shared mental models’ (Cannon-Bowers and Salas 2001, Klimoski and Mohammed 1994, Schöbel and Kleindienst 2001). Sharing mental models is critical for team problem solving because it is the process by which problem solving becomes a team activity. ‘Problem solving’ is a thinking process that integrates perception and processing of relevant clues from the environment (like a sudden drop in a patient’s blood pressure), the development of a plan and the decision for one option. Being a thinking process it can be observed only by observing speech acts accompanying thought (‘thinking aloud’) or overt behaviour. This is true for team members as well as for researchers. So, team problem solving can only occur if people share relevant thoughts using explicit communication. Shared mental models enable members of a team to gain a shared understanding of the task and to cooperate accordingly. The shared understanding of the problem allows all the participants in the operation to remain ‘in the loop’. Team research Safer Surgery 302 has highlighted the importance of shared mental models for team performance (Entin and Serfaty 1999, Orasanu 1990, Stout et al. 1999). As we see it, healthcare has willingly adopted the idea of training for team- related skills in medically critical situations (Davies 2001, Glavin and Maran 2003, Howard et al. 1992, Risser et al. 1999, Thomas et al. 2004), without putting much emphasis on the process of problem solving. Good decision-making on the other hand is a result of adequate problem solving. There is a long-standing tradition of problem-solving research in psychology (e.g., Dörner 1996, Frensch and Funke 1995), but little of that has been translated into the eld of healthcare. Research into CRM courses shows that some training programmes lead to measurable results and some do not. In spite of the diversity of results, we can conclude that CRM training in general has proven to be useful in terms of changing behaviour and values, and that it can improve the efciency of teams (Morey et al. 2002, Salas et al. 2001, 2006). Yet what we do not seem to fully understand is how improved communication skills in teams and improved decision-making interact. One pre-requisite of evaluating CRM training programmes is the development of tools for measuring behaviour. The use of behavioural markers is now a widely accepted approach in aviation (Häusler et al. 2004, Transportation 1998) where in many countries the evaluation of CRM skills has become part of the licence check (e.g., Joint Aviation Authorities 2006). Also in healthcare, over the last decade many research groups have developed sets of behavioural markers for team-related skills (e.g., Carthey et al. 2003, Fletcher et al. 2004, Gaba et al. 1998, Thomas et al. 2004, Undre et al. 2007, Yule et al. 2006). The behaviours covered are similar; communication, team leadership and decision-making are always part of the set. Thus, it seems possible to measure CRM performance in terms of the team showing certain classes of behaviour more or less adequately. But there is still a lack of knowledge about what actually happens while a healthcare team is solving problems, e.g., in an incident in the operating room (OR). How do they approach the problem? How do they nd a decision? Do they negotiate goals and plans? Do they actively build shared mental models by talking about their perception of the problem? Being psychologists interested in action and in problem solving we carried out, together with anaesthetists, an observational study on problem solving in critical incidents in the OR. We aimed to understand the process of problem solving in a team, so we developed two tools for the observation and evaluation: one for problem solving in the team and a very specic behavioural marker system for communication in dened critical incidents. The observational study was part of a research project on the development and evaluation of training of problem solving which was funded by the German Federal Ministry of Education and Research. Here, we report only our approach to observing problem solving and communication in the OR. Observing Team Problem Solving and Communication in Critical Incidents 303 Observing Problem Solving and Communication in Anaesthesia Concept Good problem solving skills are essential for team members in dynamic, high risk domains such as the OR. Since this is especially true during unexpected events we focussed on observing critical incidents within the OR. Communication is an essential part of team problem solving and is also important for the creation of a cooperative team atmosphere, for the maintenance of professional identity, and the exchange of information to coordinate routine activities (St Pierre et al. 2007). But in critical situations like incidents during an operation, communication must, above all, serve to establish and maintain a shared understanding and coordinate behaviour; the other functions of communication become secondary (a cooperative team atmosphere, e.g., must be established before an incident). When incidents in the OR occur – at least in the German hospital system – the anaesthesiologists are often responsible for coordinating the overall situation. This includes conferring with the surgeons, but also with the anaesthesia assistants, whose integration is essential. Additionally, contact must be maintained with superiors, the laboratory, the blood bank, and the intensive care unit. Anaesthesiologists plan their own behaviour and organize the team. Thus, they have a central function for the problem solving processes in the system OR. For this reason, the study presented here focuses on anaesthesiologists. As said above, little is known about the communication behaviour in the OR. Analogously to many studies of cockpit communication (e.g., Dietrich and von Meltzer 2003, Sexton and Helmreich 2000), some studies of communication in operations (e.g., Grommes 2000) have focused on the structures of language and their potential to distort communication (linguistic approach). The other approach to communication in the cockpit, the socio-psychological approach, has rarely been pursued for operations (but see Coiera and Tombs 1998). This approach understands communication as a behaviour correlate of specic attitudes, personality traits, etc. and correlates it with the team’s achievement: ‘It investigates which communicative patterns contribute to effective teamwork.’ (Silberstein 2001, p. 5) Behaviour during incidents in the operating theatre is difcult to investigate, because (at least in Germany) there are no recordings of all events in all operations, in contrast to the cockpit voice recorder and ‘black box’ in aviation. Field observations would be uneconomical due to the low frequency of critical incidents. Furthermore, in real crisis situations, the presence of an observer may be a distraction. For this reason, the study presented here captured on video and analysed incidents processed in the anaesthesia simulator. In the setting used for this study, the surgical side of the simulator is not realized so the surgeons and nursing staff simply play a role. The nursing staff’s eld of activity during . Vincent, C.A. (2007) Observational Teamwork Assessment for Surgery (OTAS): Renement and application in urological surgery. World Journal of Surgery 31(7), 1373–81. This page has been left blank. accordingly. The shared understanding of the problem allows all the participants in the operation to remain ‘in the loop’. Team research Safer Surgery 302 has highlighted the importance of shared mental. silence. ‘Counting silence’ is a complicated but necessary business for performance evaluation for safer surgery: silence can promote safety when team members ‘count to ten’ and think before acting,