Intra-operative decision making by ophthalmic surgeons

PURPOSE

Research on surgical decision making and risk management usually focuses on peri-operative care, despite the magnitude and frequency of intra-operative risks. The aim of this study was to examine ophthalmic surgeons' intra-operative decisions and risk management strategies in order to explore differences in cognitive processes.

METHOD

Critical decision method interviews were conducted with 12 consultant ophthalmologists who recalled cases and selected important decisions during the operations. These decisions were then discussed in detail in relation to decision making style and risk management. Transcripts were coded according to decision making strategy (analytical, recognition primed decision, creative and rule-based) and risk management (threats, risk assessment and risk tolerance).

RESULTS

The key decision in each case was made using either a rapid, intuitive mode of thinking (n=6, 50%) or a more deliberate comparison of alternative courses of action (n=6, 50%). Rule-based or creative decision making was not used. Risk management involved the perception of threats and assessment of threat impact but was also influenced by personal risk tolerance. Risk tolerance seemed to play a major role during situations requiring a stopping rule. Risk management did not appear to be influenced by time pressure.

CONCLUSIONS

Surgeons described making key intra-operative decisions using either an intuitive or an analytical mode of thinking. Ophthalmic surgeons' risk assessment, risk tolerance and decision strategies appear to be influenced by personality.

Patient safety climate and worker safety behaviours in acute hospitals in Scotland

OBJECTIVES

To obtain a measure of hospital safety climate from a sample of National Health Service (NHS) acute hospitals in Scotland and to test whether these scores were associated with worker safety behaviors, and patient and worker injuries.

METHODS

Data were from 1,866 NHS clinical staff in six Scottish acute hospitals. A Scottish Hospital Safety Questionnaire measured hospital safety climate (Hospital Survey on Patient Safety Culture), worker safety behaviors, and worker and patient injuries. The associations between the hospital safety climate scores and the outcome measures (safety behaviors, worker and patient injury rates) were examined.

RESULTS

Hospital safety climate scores were significantly correlated with clinical workers' safety behavior and patient and worker injury measures, although the effect sizes were smaller for the latter. Regression analyses revealed that perceptions of staffing levels and managerial commitment were significant predictors for all the safety outcome measures. Both patient-specific and more generic safety climate items were found to have significant impacts on safety outcome measures.

CONCLUSION

This study demonstrated the influences of different aspects of hospital safety climate on both patient and worker safety outcomes. Moreover, it has been shown that in a hospital setting, a safety climate supporting safer patient care would also help to ensure worker safety.

IMPACT ON INDUSTRY

The Scottish Hospital Safety Questionnaire has proved to be a usable method of measuring both hospital safety climate as well as patient and worker safety outcomes.

Development of a behavioural marker system for scrub practitioners' non-technical skills (SPLINTS system)

RATIONALE, AIMS AND OBJECTIVES

Adverse events still occur despite ongoing efforts to reduce harm to patients. Contributory factors to adverse events are often due to limitations in clinicians' non-technical skills (e.g. communication, situation awareness), rather than deficiencies in technical competence. We developed a behavioural rating system to provide a structured means for teaching and assessing scrub practitioners' (i.e. nurse, technician, operating department practitioner) non-technical skills.

METHOD

Psychologists facilitated focus groups (n = 4) with experienced scrub practitioners (n = 16; 4 in each group) to develop a preliminary taxonomy. Focus groups reviewed lists of non-technical-skill-related behaviours that were extracted from an interview study. The focus groups labelled skill categories and elements and also provided examples of good and poor behaviours for those skills. An expert panel (n = 2 psychologists; n = 1 expert nurse) then used an iterative process to individually and collaboratively review and refine those data to produce a prototype skills taxonomy.

RESULTS

A preliminary taxonomy containing eight non-technical skill categories with 28 underlying elements was produced. The expert panel reduced this to three categories (situation awareness, communication and teamwork, task management), each with three underlying elements. The system was called the Scrub Practitioners' List of Intraoperative Non-Technical Skills system. A scoring system and a user handbook were also developed.

CONCLUSION

A prototype behavioural rating system for scrub practitioners' non-technical skills was developed, to aid in teaching and providing formative assessment. This important aspect of performance is not currently explicitly addressed in any educational route to qualify as a scrub practitioner.

Team communication during patient handover from the operating room: more than facts and figures

OBJECTIVE

This study was aimed at examining team communication during postoperative handover and its relationship to clinicians' self-ratings of handover quality.

BACKGROUND

Adverse events can often be traced back to inadequate communication during patient handover. Research and improvement efforts have mostly focused on the information transfer function of patient handover. However, the specific mechanisms between handover communication processes among teams of transferring and receiving clinicians and handover quality are poorly understood.

METHOD

We conducted a prospective, cross-sectional observation study using a taxonomy for handover behaviors developed on the basis of established approaches for analyzing teamwork in health care. Immediately after the observation, transferring and receiving clinicians rated the quality of the handover using a structured tool for handover quality assessment. Handover communication during 117 handovers in three postoperative settings and its relationship to clinicians' self-ratings of handover quality were analyzed with the use of correlation analyses and analyses of variance.

RESULTS

We identified significantly different patterns of handover communication between clinical settings and across handover roles. Assessments provided during handover were related to higher ratings of handover quality overall and to all four dimensions of handover quality identified in this study. If assessment was lacking, we observed compensatory information seeking by the receiving team.

CONCLUSION

Handover quality is more than the correct, complete transmission of patient information. Assessments, including predictions or anticipated problems, are critical to the quality of postoperative handover.

APPLICATION

The identification of communication behaviors related to high-quality handovers is necessary to effectively support the design and evaluation of handover improvement efforts.

Using Videos to Determine the Effect of Stage of Operation and Intraoperative Events on Surgeons’ Intraoperative Leadership

Background Leadership is a key component for the successful functioning of teams and the achievement of task goals. During the intraoperative phase of surgery, the attending surgeon can be likened to a team leader with responsibility for task accomplishment by a small team. This study identified and evaluated surgeons’ leadership behaviors during operations, with particular reference to any changes that occurred following two types of events. Method Videos of live operations ( n=29) from the operating rooms of three teaching hospitals in the UK were analyzed to identify and code surgeons’ intraoperative leadership behaviors using the Surgeons’ Leadership Inventory (SLI). The frequency and quality of the leadership behaviors were compared before and after the point of no return (PONR) (n=24) and before and after an unexpected intraoperative event (n=5). Results Most leadership behaviors were directed toward the resident during an operation. No significant differences were found for the overall frequency or quality of leadership behaviors pre- and post-PONR. The frequency of leadership behaviors classified as ‘training’ and ‘Supporting others’ significantly decreased after an unanticipated intraoperative event. Discussion This study provides a detailed description of surgeons’ intraoperative leadership during different types of operative situations and stages. During the intraoperative period, the attending surgeon seemed to lead the surgical trainee almost exclusively, and not other members of the operative team. Leadership was highly focused on the surgical task.

Paramedics' non-technical skills: a literature review

Healthcare organisations have started to examine the impact that the human worker has on patient safety. Adopting the Crew Resource Management (CRM) approach, used in aviation, the CRM or non-technical skills of anaesthetists, surgeons, scrub practitioners and emergency physicians have recently been identified to assist in their training and assessment. Paramedics are exposed to dynamic and dangerous situations where patients have to be managed, often with life-threatening injuries or illness. As in other safety-critical domains, the technical skills of paramedics are complemented by effective non-technical skills. The aim of this paper was to review the literature on the non-technical (social and cognitive) skills used by paramedics. This review was undertaken as part of a task analysis to identify the non-technical skills used by paramedics. Of the seven papers reviewed, the results have shown very little research on this topic and so reveal a gap in the understanding of paramedic non-technical skills.

Surgeons' leadership in the operating room: an observational study

BACKGROUND

There is widespread recognition in high-risk organizations that leadership is essential for efficient and safe team performance. However, there is limited empiric evidence identifying specific leadership skills and associated behaviors enacted by surgeons during surgery.

METHODS

Observational data on surgeons' intraoperative leadership behaviors were gathered during surgeries (n = 29) in 3 hospitals. Observations were coded using 7 leadership elements identified from the literature on surgeons' leadership. Surgeries were categorized by complexity using British United Provident Association ratings.

RESULTS

A total of 258 leadership behaviors were observed during more than 63 hours of observation. Surgeons most frequently showed guiding and supporting (33%), communicating and coordinating (20%), and task management behaviors (15%). In many instances the surgeons' leadership was directed to the room rather than to a specific team member. Surgeons engaged in leadership behaviors significantly more frequently during cases of high complexity compared with cases of lower complexity.

CONCLUSIONS

This study is the first step in developing an empirically derived taxonomy to identify and classify surgeons' intraoperative leadership behaviors.

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis

AIM

To examine the ideal and actual processes of doctors' handovers in an acute medical assessment unit by means of a hierarchical task analysis (HTA) to identify any discrepancies between the ideal shift handover process as described by doctors, and the actual shift handover process as observed by the researcher.

METHOD

The HTA was constructed using information gathered from interviews (n=13) describing the activities doctors said they should ideally perform in preparation for the shift handover meeting, during the meeting and after the meeting has finished. Observations (n=32) were made pre handover, during handover and post handover to capture the actual handover process in the acute medical assessment unit. Furthermore, a focus group discussion was included to validate the researcher's observations of the actual handover process and to provide content validity to the constructed HTA of the ideal handover process.

RESULTS

Findings as represented by the HTA diagram showed the complexity of the process. The diagram revealed critical tasks that should be completed at each phase of the handover process, but observations revealed that these were sometimes omitted, mainly due to work demands and time pressure. These omissions were most apparent in the pre-handover stage, resulting in interrupted, extended and/or delayed handover meetings.

CONCLUSION

The pre-handover phase is critical in providing a foundation for a thorough handover meeting and potentially helping doctors who have started a shift to prioritise patient care. These findings suggest that quality improvements for clinical handovers should include a designated time for preparation of care transfer information.

Hospital survey on patient safety culture: psychometric analysis on a Scottish sample

OBJECTIVE

To investigate the psychometric properties of the Hospital Survey on Patient Safety Culture on a Scottish NHS data set.

METHODS

The data were collected from 1969 clinical staff (estimated 22% response rate) from one acute hospital from each of seven Scottish Health boards. Using a split-half validation technique, the data were randomly split; an exploratory factor analysis was conducted on the calibration data set, and confirmatory factor analyses were conducted on the validation data set to investigate and check the original US model fit in a Scottish sample.

RESULTS

Following the split-half validation technique, exploratory factor analysis results showed a 10-factor optimal measurement model. The confirmatory factor analyses were then performed to compare the model fit of two competing models (10-factor alternative model vs 12-factor original model). An S-B scaled χ(2) square difference test demonstrated that the original 12-factor model performed significantly better in a Scottish sample. Furthermore, reliability analyses of each component yielded satisfactory results. The mean scores on the climate dimensions in the Scottish sample were comparable with those found in other European countries.

CONCLUSIONS

This study provided evidence that the original 12-factor structure of the Hospital Survey on Patient Safety Culture scale has been replicated in this Scottish sample. Therefore, no modifications are required to the original 12-factor model, which is suggested for use, since it would allow researchers the possibility of cross-national comparisons.

Safe eye surgery: non-technical aspects

The traditional training of surgeons focused exclusively on developing knowledge, clinical expertise, and technical (surgical) skills. However, analyses of the reasons for adverse events in surgery have revealed that many underlying causes originate from behavioural or non-technical aspects of performance (eg, poor communication among members of the surgical team) rather than from a lack of surgical (ie, technical) skills. Therefore, technical skills appear to be necessary but not sufficient to ensure patient safety. Paying attention to non-technical skills, such as team working, leadership, situation awareness, decision making, and communication, will increase the likelihood of maintaining high levels of error-free performance. Identification and training of non-technical skills has been developed for high-risk careers, such as civil aviation and nuclear power. Only recently, training in non-technical skills has been adopted by the surgical world and anaesthetists. Non-technical skills need to be tailored to the environment where they are used, and eye surgery has some substantial differences compared with other surgical areas, for example, high volume of surgery, use of local anaesthetics, and very sophisticated equipment. This review highlights the need for identification of the non-technical skills relevant to eye surgeons and promotion of their use in the training of eye surgeons.

Doctors' handovers in hospitals: a literature review

AIM

To review studies on hospital doctors' handovers to identify the methods and main findings.

METHOD

A literature search of electronic databases Medline and Embase (via Ovid) was conducted against a set of inclusion criteria.

RESULTS

A total of 32 papers were identified. The most common methods of studying handovers were observations and interviews, which typically focused on the sign-out (ie, handover meeting). This is just one stage of the handover process: pre- and posthandover phases were rarely examined. Although providing useful descriptive information, the studies rarely evaluated the quality of handover practices. While communication is generally recognised as the critical component, there has been little training of this skill.

CONCLUSION

The handover literature does not fully identify where communication failures typically occur or influencing conditions, thus hampering the design of effective handover training and tools. A systematic analysis of all the stages of doctors' handovers is required.

Thinking ahead of the surgeon. An interview study to identify scrub nurses' non-technical skills

BACKGROUND

Efforts to reduce adverse event rates in healthcare have revealed the importance of identifying the essential non-technical (cognitive and social) skills for safe and effective performance. Previous research on non-technical skills for operating theatre staff has concentrated on doctors rather than nursing professionals.

OBJECTIVES

The aim of the study was to identify the critical non-technical skills that are essential for safe and effective performance as an operating theatre scrub nurse.

METHODS

Experienced scrub nurses (n = 25) and consultant surgeons (n = 9) from four Scottish hospitals were interviewed using a semi-structured format. The protocols were designed to identify the main social and cognitive skills required by scrub nurses. Interviews were digitally recorded, transcribed verbatim and independently coded to extract behaviours in order to produce a list of the main non-technical skills for safe and effective scrub nurse performance.

RESULTS

The non-technical skills of situation awareness, communication, teamwork, task management and coping with stress were identified as key to successful scrub nurse task performance. Component sets of behaviours for each of these categories were also noted.

CONCLUSION

The interviews with subject matter experts from scrub nursing and surgery produced preliminary evidence that situation awareness, communication, teamwork and coping with stress are the principal non-technical skills required for effective performance as a scrub nurse.