'Achieving ensemble': communication in orthopaedic surgical teams and the development of situation awareness--an observational study using live videotaped examples

The development of a research-based interprofessional communication behaviors repository in healthcare education: A systematic review

Interprofessional communication is crucial for patient care, yet there is a dearth of comprehensive assessment tools essential to train and assess healthcare students. While the Interprofessional Educational Collaborative framework (IPEC) outlines eight sub-competencies, it lacks detailed behavioral indicators. This study aimed to create a repository of interprofessional communication behaviors to complement the IPEC sub-competencies. From 12,448 articles, 55 were selected and thematically analyzed with NVivo18®. We identified 230 interprofessional communication behaviors, organized into 10 themes and 61 sub-themes, aligning with the IPEC sub-competencies. This comprehensive repository could be foundational for developing interprofessional communication assessment tools in healthcare education and aiding healthcare institutions in improving interprofessional communication practices.

Acoustic Biotopes, Listeners and Sound-Induced Action: A Case Study of Operating Rooms

As socio-technological environments shape and direct listener behaviour, an ecological account is needed that encompasses listening in complexity (i.e., multiple listeners, multiple sounds and their sources, and multiple sound-induced actions that ensure the success of a mission). In this study, we explored sound-induced action under the framework of "acoustic biotopes" (a notion of ecological acoustics by Smolders, Aertsen, and Johanessma, 1979 and 1982) in a specific socio-technological environment, i.e., the context of an orthopaedic operating room. Our approach is based on literature research into the topics of environmental psychology and auditory perception and action and in situ observations in healthcare with field recordings, participatory observations, and interviews on the spot. The results suggest a human-centered definition of sound-induced action in acoustic biotopes: Acoustic biotope is an active and shared sound environment with entangled interactions and sound-induced actions taking place in a specific space that has a critical function. Listening in highly functional environments is an individual experience and is influenced by hearing function, physical position and role in an environment, and the task at hand. There is a range of active and passive sound listeners as a function of their attentive state and listeners as sound sources within the acoustic biotope. There are many different sound sources and sound locals in socio-technological environments and sounds have great potential to serve critical information to operators. Overall, our study provides a holistic, multi-layered and yet a listener-centric view on the organisation of complex spaces and the results can immediately be applicable for rethinking the acoustic environment for ORs for better listening and sound-induced action.

The who, what, and how of teamwork research in medical operating rooms: A scoping review

Despite the importance of teamwork in the operating room (OR), teamwork can often be conflated with teamwork components (e.g., communication, cooperation). We reviewed the existing literature pertaining to OR teamwork to understand which teamwork components have been assessed. Following PRISMA guidelines for scoping reviews, 4,233 peer-reviewed studies were identified using MEDLINE and Embase. Eighty-seven studies were included for synthesis and analysis. Using the episodic model of teamwork as an organizing framework, studies were grouped into the following teamwork categories: (a) transition processes (e.g., goal specification), (b) action processes (e.g., coordination), (c) interpersonal processes (e.g., conflict management), (d) emergent states (e.g., psychological safety), or (e) omnibus topics (a combination of higher-order teamwork processes). Results demonstrated that action processes were most frequently explored, followed by transition processes, omnibus topics, emergent states, and interpersonal processes. Although all studies were framed as investigations of teamwork, it is important to highlight that most explored only one or a few constructs under the overarching umbrella of teamwork. We advocate for enhanced specificity with descriptions of OR teamwork, reporting practices pertaining to interprofessional demographics and outcomes, and increased diversity in study design and surgery type to advance understanding of teamwork and its implications.

Situation awareness and the mitigation of risk associated with patient deterioration: A meta-narrative review of theories and models and their relevance to nursing practice

BACKGROUND

Accurate situation awareness has been identified as a critical component of effective deteriorating patient response systems and an essential patient safety skill for nursing practice. However, situation awareness has been defined and theorised from multiple perspectives to explain how individuals, teams and systems maintain awareness in dynamic task environments.

AIM

Our aim was to critically analyse the different approaches taken to the study of situation awareness in healthcare and explore the implications for nursing practice and research as it relates to clinical deterioration in ward contexts.

METHODS

We undertook a meta-narrative review of the healthcare literature to capture how situation awareness has been defined, theorised and studied in healthcare. Following an initial scoping review, we conducted an extensive search of ten electronic databases and included any theoretical, empirical or critical papers with a primary focus on situation awareness in an inpatient hospital setting. Included papers were collaboratively categorised in accordance with their theoretical framing, research tradition and paradigm with a narrative review presented.

RESULTS

A total of 120 papers were included in this review. Three overarching narratives reflecting philosophical, patient safety and solution focussed framings of situation awareness and seven meta-narratives were identified as follows: individual, team and systems perspectives of situation awareness (meta-narratives 1-3), situation awareness and patient safety (meta-narrative 4), communication tools, technologies and education to support situation awareness (meta-narratives 5-7). We identified a concentration of literature from anaesthesia and operating rooms and a body of research largely located within a cognitive engineering tradition and a positivist research paradigm. Endsley's situation awareness model was applied in over 80% of the papers reviewed. A minority of papers drew on alternative situation awareness theories including constructivist, collaborative and distributed perspectives.

CONCLUSIONS

Nurses have a critical role in identifying and escalating the care of deteriorating patients. There is a need to build on prior studies and reflect on the reality of nurse's work and the constraints imposed on situation awareness by the demands of busy inpatient wards. We suggest that this will require an analysis that complements but goes beyond the dominant cognitive engineering tradition to reflect the complex socio-cultural reality of ward-based teams and to explore how situation awareness emerges in increasingly complex, technologically enabled distributed healthcare systems.

Accountable Operating Room Teams

With Medicare reimbursement diminishing and the aging population consuming more health care, hospitals continue to push for reforms to improve the efficiency of health care delivery, decrease consumption, and elevate the quality of care. Operating rooms command a large share of hospital resources but are also major revenue generators. Surgical care has evolved to become more efficient and accountable. Defining the characteristics of an accountable operating room team has been more elusive and inconsistent. This review defines the characteristics of accountable operating room teams and recommends measures by which to evaluate them. [Orthopedics. 2021;44(4):e463-e470.].

Becoming the temporary surgeon: A grounded theory examination of anaesthetists performing emergency front of neck access in inter-disciplinary simulation-based training

The time-critical 'can't intubate, can't oxygenate' [CICO] emergency post-induction of anaesthesia is rare, but one which, should it occur, requires Anaesthetists to perform rapid emergency front of neck access [FONA] to the trachea, restoring oxygenation, and preventing death or brain hypoxia. The UK Difficult Airway Society [DAS] has directed all Anaesthetists to be trained with surgical cricothyroidotomy [SCT] as the primary emergency FONA method, sometimes referred to as 'Cric' as a shorthand. We present a longitudinal analysis using a classical approach to Grounded Theory methodology of ten Specialist Trainee Anaesthetists' data during a 6-month training programme delivered jointly by Anaesthetists and Surgeons. We identified with a critical realist ontology and an objectivist epistemology meaning data interpretation was driven by participants' narratives and accepted as true accounts of their experience. Our theory comprises three themes: 'Identity as an Anaesthetist'; 'The Role of a Temporary Surgeon'; and 'Training to Reconcile Identities', whereby training facilitated the psychological transition from a 'bloodless Doctor' (Anaesthetist) to becoming a 'temporary Surgeon'. The training programme enabled Specialist Trainees to move between the role of control and responsibility (Identity as an Anaesthetist), through self-described 'failure' and into a role of uncertainty about one's own confidence and competence (The Role of a Temporary Surgeon), and then return to the Anaesthetist's role once the airway had been established. Understanding the complexity of an intervention and providing a better insight into the training needs of Anaesthetic trainees, via a Grounded Theory approach, allows us to evaluate training programmes against the recognised technical and non-technical needs of those being trained.

Micro-relational interdependencies are the essence of teaching and learning in the OR

CONTEXT

In the high-stakes, time-critical environment of the operating room (OR), attendings and residents strive to complete safe, effective surgeries and ensure that learning occurs. Yet meaningful resident participation often receives less attention, and that impedes residents' ability to learn and achieve autonomous operative practice. We need a new conceptual framework for understanding progression to autonomous practice that can guide both faculty and residents. Thus, we sought a new conceptualisation of intraoperative teaching and learning (IOT&L) through the lens of Eraut's notion of informal workplace learning and Billett's theory of relational interdependence between social and individual agency.

METHODS

We viewed authentic examples of IOT&L in video and transcripts of live OR cases and interviews with participating attendings and residents. By systematically applying Eraut and Billet's theories to the transcripts and interviews, we developed concrete descriptions about how IOT&L occurs, categorised them into theory-based principles and derived a conceptualisation and related research ideas about IOT&L.

RESULTS

Established workplace learning theories frame IOT&L as socially negotiated processes transpiring in distinct interdependent interactions between residents' individual cognitive experiences and their OR social experiences that direct their learning. As the surgery unfolds, spontaneous events and the rules of surgery create opportunities for unplanned and informal learning. These authentic interrelated cognitive and social experiences are stimulated when residents reveal a learning need or attendings recognise a learning gap, and efforts ensue to bridge that gap. Through these minute distinct exchanges, labelled here as 'atomic' IOT&L, residents gain crucial knowledge and skill.

CONCLUSION

Framing authentic OR interactions between attendings and residents in terms of micro-relational interdependencies shows how granular teaching/learning exchanges yield high-value informal learning. To improve IOT&L, we must examine and change it at this fundamental level by using and testing this new theoretical conceptualisation. These insights produced ideas about IOT&L to test and research.

Effective Surgical Teams: An Integrative Literature Review

It is imperative to understand the factors that contribute to effective surgical teams. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety. The literature search was undertaken of 15 databases, which resulted in 70 articles being included. It was found perioperative teamwork was not widely understood. Findings indicated barriers to effective surgical teams comprised of confusion in tasks and responsibilities, existing hierarchies and prevailing misconceptions and understanding among team members. Although numerous quality initiatives exist, the introduction of protocols and checklists, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue. Further research is recommended to obtain a comprehensive perception of environmental influences and barriers surgical teams encounter in the delivery of safe quality care.

The importance of non-technical skills in modern surgical practice

The significance of technical skills and manual dexterity for surgeons is an indisputable fact. However, the systematic study of medical errors has revealed that a significant percentage of these errors are caused by factors related to non-technical skills. The review presented in this article intends to describe and explore the relevance of these non-technical skills, including: situational awareness, decision-making, leadership and communication. In conclusion, the authors propose that adequate importance needs to be given to these aptitudes to provide safe clinical care.

Creating a safer operating room: Groups, team dynamics and crew resource management principles

The operating room (OR) is a special place wherein groups of highly skilled individuals must work in a coordinated and harmonious fashion to deliver optimal patient care. Team dynamics and human factors principles were initially studied by the aviation industry to better understand and prevent airline accidents. As a result, crew resource management (CRM) training was designed for all flight personnel to create a highly reliable industry with a commitment to a culture of safety. CRM has since been adapted to health care, resulting in care improvement and harm reduction across a wide variety of medical specialties. When implemented in the OR, CRM has been shown not only to improve communication and morale for OR staff, but also reduce morbidity and mortality for patients. As increasing focus is placed on quality, safety, and high-reliability, surgeons will be expected to participate and lead efforts to facilitate a team approach in this new era of patient care.

Factors that affect scrub practitioner non-technical skills: A literature review

Non-technical skills are the cognitive and interpersonal behaviours that compliment clinical competence in surgery. Effective use of non-technical skills is essential for scrub practice, because they facilitate anticipation of the surgeon's requirements and promote appropriate communication behaviours. This literature review analyses the factors that may influence a scrub practitioner's use of non-technical skills during surgery. Recommendations are made that are intended to improve their use by reducing behavioural variations during surgery.

State-of-science: situation awareness in individuals, teams and systems

Our review addresses one of the most used, but debated, topics in Ergonomics: Situation Awareness (SA). We examine and elaborate upon key SA models. These models are divided into individual SA, team SA and systems SA categories. Despite, or perhaps because of, the debates surrounding SA it remains an enduring theme for research and practice in the domain of Ergonomics, now for over two decades. A contingent approach, which seeks to match different models of SA to different types of ergonomics problem, enables the differences between positions to be revealed and reconciled, and the practitioner guided towards optimum methodological solutions. Practitioner Summary: Measuring SA in individuals, teams and systems has become a key objective in Ergonomics. One single approach to SA does not fit all problems encountered. This review shows the importance of considering all three types of models and achieving a match between them and the problem at hand.

What would you ideally do if there were no targets? An ethnographic study of the unintended consequences of top-down governance in two clinical settings

Top-down policy directives, such as targets and their associated protocols, may be driven politically rather than clinically and can be described as macro-political texts. While targets supposedly provide incentives for healthcare services, they may unintentionally shape practices of accommodation rather than implementation, deflecting practitioners from providing optimal care. Live work activities were observed for two six months periods in a UK NHS Emergency Department and a Mental Health Ward using video and field notes ethnography, with post hoc unstructured interviews for clarification and verification. Sixty-four practitioners were consented. Data were treated as narratives, analysed thematically and theorised using cultural-historical activity theory. The ideal text of patient-centred team working shaped by top-down, politically inspired targets was disrupted, where targets produced unintended consequences. Bottom-up strategies of making meaning of targets in a local context generated sub-texts of resistance, rationalization, and even duplicity that had paradoxical positive effects in generating collaboration and democratic habits. Throughput pressures generated both cross-team conflicts and intra-team identification. What practitioners actually do to make sense of top-down directives is not the same as the ideal expectation framed by targets. Team members pulled together not because of targets but in spite of them, and as a form of resistance to governance. Targets produce unnecessary stress as team members focus on throughput rather than quality of care. Those governing healthcare must look at the unintended consequences of targets.

Team communication amongst clinical teachers in a formal meeting of post graduate medical training

The importance of team communication, or more specifically speaking up, for safeguarding quality of patient care is increasingly being endorsed in research findings. However, little is known about speaking up of clinical teachers in postgraduate medical training. In order to determine how clinical teachers demonstrate speaking up in formal teaching team meetings and what factors influence this, the authors carried out an exploratory study based on ethnographic principles. The authors selected 12 teaching teams and observed, audio recorded and analysed the data. Subsequently, during an interview, the program directors reflected on speaking up of those clinical teachers present during the meeting. Finally, the authors analysed iteratively all data, using a template analysis, based on Edmondson's behaviours of speaking up. The study was conducted from October 2013 to July 2014 and ten teams participated. During the teaching team meetings, the clinical teachers exhibited most of the behaviours of speaking up. "Sharing information" strongly resembles providing information and "talking about mistakes" occurs in a general sense and without commitment of improvement activities. "Asking questions" was often displayed by closed questions and at times several questions simultaneously. The authors identified factors that influence speaking up by clinical teachers: relational, cultural, and professional. The clinical teachers exhibit speaking up, but there is only limited awareness to discuss problems or mistakes and the discussion centred mainly on the question of blame. It is important to take into account the factors that influence speaking up, in order to stimulate open communication during the teaching team meetings.

Dimensions, discourses and differences: trainees conceptualising health care leadership and followership

CONTEXT

As doctors in all specialties are expected to undertake leadership within health care organisations, leadership development has become an inherent part of medical education. Whereas the leadership literature within medical education remains mostly focused on individual, hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation. This gap between theory and practice indicates that there is a need to understand what leadership and followership mean to medical trainees working in today's interprofessional health care workplace.

METHODS

Epistemologically grounded in social constructionism, this research involved 19 individual and 11 group interviews with 65 UK medical trainees across all stages of training and a range of specialties. Semi-structured interviewing techniques were employed to capture medical trainees' conceptualisations of leadership and followership. Interviews were audiotaped, transcribed verbatim and analysed using thematic framework analysis to identify leadership and followership dimensions which were subsequently mapped onto leadership discourses found in the literature.

RESULTS

Although diversity existed in terms of medical trainees' understandings of leadership and followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy and personality were commonplace in trainees' understandings. This indicated the dominance of an individualist discourse. Patterns in understandings across all stages of training and specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily influenced trainees' conceptualisations of leadership and followership.

CONCLUSIONS

Our findings suggest that UK trainees typically hold traditional understandings of leadership and followership, which are clearly influenced by the organisational structures in which they work. Although education may change these understandings to some extent, changes in leadership practices to reflect contemporary theory are unlikely to be sustained if leadership experiences in the workplace continue to be based on individualist models.

Observation for assessment of clinician performance: a narrative review

BACKGROUND

Video recorded and in-person observations are methods of quality assessment and monitoring that have been employed in high risk industries. In the medical field, observations have been used to evaluate the quality and safety of various clinical processes. This review summarises studies utilising video recorded or in-person observations for assessing clinician performance in medicine and surgery.

METHODS

A search of MEDLINE (PubMed) was conducted using a combination of medical subject headings (MeSH) terms. Articles were included if they described the use of in-person or video recorded observations to assess clinician practices in three categories: (1) teamwork and communication between clinicians; (2) errors and weaknesses in practice; and (3) compliance and adherence to interventions or guidelines.

RESULTS

The initial search criteria returned 3215 studies, 223 of which were identified for full text review. A total of 69 studies were included in the final set of literature. Observations were most commonly used in data dense and high risk environments, such as the emergency department or operating room. The most common use was for assessing teamwork and communication factors.

CONCLUSIONS

Observations are useful for the improvement of healthcare delivery through the identification of clinician lapses and weaknesses that affect quality and safety. Limitations of observations include the Hawthorne effect and the necessity of trained observers to capture and analyse the notes or videos. The comprehensive, subtle and sensitive information observations provided can supplement traditional quality assessment methods and inform targeted interventions to improve patient safety and the quality of care.

Towards culture change in the operating theatre: embedding a complex educational intervention to improve teamwork climate

BACKGROUND

Changing teamwork climate in healthcare through a collective shift in attitudes and values may be a necessary precursor to establishing a positive teamwork culture, where innovations can be more readily embedded and sustained. A complex educational intervention was initiated across an entire UK Trust's surgical provision, and then sustained. Attitudes towards teamwork were measured longitudinally to examine if the intervention produced sustainable results.

AIMS

The research aimed to test whether sustaining a complex education intervention to improve teamwork would result in an incremental, longitudinal improvement in attitudes and values towards teamwork. The intervention's larger aim is to progress the historical default position of multi-professional work to authentic inter-professional teamwork, as a positive values climate translates in time into behavioural change defining a safety culture.

METHOD

Attitudes were measured at three points across all surgical team personnel over a period of 4 years, using a validated Safety Attitudes Questionnaire with a focus on the 'teamwork climate' domain. Pre- and post-intervention 'teamwork climate' scores were compared to give a longitudinal measure as a test of sustainability.

RESULTS

Mean 'teamwork climate' scores improved incrementally and significantly following the series of educational interventions, showing that practitioners' valuing of teamwork activity can be improved and sustained.

CONCLUSIONS

Longitudinal positive change in attitudes and values towards teamwork can be sustained, suggesting that a deliberate, designed complex intervention can shape a safety climate as a necessary prerequisite for the establishment of a sustainable safety culture.