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Chrouser KL, Partin MR, Gainsburg I, White KM. Examining the surgical stress effects (SSE) framework in practice: A qualitative assessment of perceived sources and consequences of intraoperative stress in surgical teams. Am J Surg 2024; 228:133-140. [PMID: 37689567 DOI: 10.1016/j.amjsurg.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/19/2023] [Accepted: 08/25/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Surgical adverse events persist despite extensive improvement efforts. Emotional and behavioral responses to stressors may influence intraoperative performance, as illustrated in the surgical stress effects (SSE) framework. However, the SSE has not been assessed using "real world" data. METHODS We conducted semi-structured interviews with all surgical team roles at one midwestern VA hospital and elicited narratives involving intraoperative stress. Two coders inductively identified codes from transcripts. The team identified themes among codes and assessed concordance with the SSE framework. RESULTS Throughout 28 interviews, we found surgical stress was ubiquitous, associated with a variety of factors, including adverse events. Stressors often elicited frustration, anger, fear, and anxiety; behavioral reactions to negative emotions frequently were perceived to degrade individual/team performance and compromise outcomes. Narratives were consistent with the SSE framework and support adding a process outcome (efficiency) and illustrating how adverse events can feedback and acutely increase job demands and stress. CONCLUSION This qualitative study describes narratives of intraoperative stress, finding they are consistent with the SSE while also allowing minor improvements to the current framework.
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Affiliation(s)
- Kristin L Chrouser
- Minneapolis VA Healthcare System, 1 Veterans Dr, Minneapolis, MN, 55417, USA; Department of Urology, University of Michigan, 2800 Plymouth Rd, NCRC Building 16, #147S, Ann Arbor, MI, 48109-2800, USA.
| | - Melissa R Partin
- Minneapolis VA Healthcare System, 1 Veterans Dr, Minneapolis, MN, 55417, USA; Department of Urology, University of Michigan, 2800 Plymouth Rd, NCRC Building 16, #147S, Ann Arbor, MI, 48109-2800, USA; Hennepin Healthcare Research Institute, 701 Park Ave, Ste PP7.700, Minneapolis, MN, 55415, USA.
| | - Izzy Gainsburg
- Harvard Kennedy School, 79 John F. Kennedy St, Cambridge, MA, 02138, USA; Department of Psychology, University of Michigan, 1004 East Hall, 530 Church St Ann Arbor, MI, 48109, USA.
| | - Katie M White
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
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Lee H, Woodward-Kron R, Merry A, Weller J. Emotions and team communication in the operating room: a scoping review. MEDICAL EDUCATION ONLINE 2023; 28:2194508. [PMID: 36995978 PMCID: PMC10064827 DOI: 10.1080/10872981.2023.2194508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/20/2023] [Accepted: 03/20/2023] [Indexed: 06/19/2023]
Abstract
Training in healthcare team communication has largely focused on strategies to improve information transfer with less focus on interpersonal dynamics and emotional aspects of communication. The Operating Room (OR) may be one of the most emotionally charged hospital environments, and is one requiring excellent team communications. We aimed to identify literature reporting on the emotional aspects of OR team communication. Our research questions were: what are the triggers in the environment that provoke an emotional response affecting communication, and what are the emotional responses to communication between OR team members; and how do these emotional aspects of communication affect the function of the OR team? We undertook a Scoping Review of literature across relevant databases following published guidelines, and narrative synthesis of the identified studies. From the 10 included studies we identified three themes: (1) Emotional experiences in the OR and their contributors; (2) Effects of emotional experiences on team communication; and (3) Solutions to manage the emotional experiences in the OR. Theme 1 sub-themes were: (1) Range of emotions experienced in the OR; (2) Hierarchical culture and (3) Leadership expectations as contributors to negative emotions. The OR is an emotionally charged environment. The hierarchical culture can inhibit staff from speaking up, and failure of leaders to meet team expectations, e.g., through appropriate and timely communication, may cause frustration and stress. The consequences of emotions include poor team dynamics, ineffective communication and potential negative impact on patient care. Few studies described strategies to manage emotions in the OR. The studies reviewed describe an environment where emotions can run high, affecting interpersonal communications, team function and patient care. The few identified studies relevant to our research questions demonstrate a need to better understand the emotional aspects of OR team communication and the effectiveness of interventions to improve these.
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Affiliation(s)
- Henrietta Lee
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Grafton,Auckland1023, New Zealand
| | - Robyn Woodward-Kron
- Department of Medical Education, Melbourne Medical School, The University of Melbourne, Parkville, VIC3010, Australia
| | - Alan Merry
- Department of Anaesthesiology, School of Medicine, The University of Auckland, Grafton, Auckland1023, New Zealand
- Honorary Consultant, Department of Anaesthesia and Perioperative Care, Auckland City Hospital, Park Rd, Grafton, Auckland1023, New Zealand
| | - Jennifer Weller
- Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Grafton,Auckland1023, New Zealand
- Honorary Consultant, Department of Anaesthesia and Perioperative Care, Auckland City Hospital, Park Rd, Grafton, Auckland1023, New Zealand
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Lee A, Torkamani-Azar M, Zheng B, Bednarik R. Unpacking the Broad Landscape of Intraoperative Stressors for Clinical Personnel: A Mixed-Methods Systematic Review. J Multidiscip Healthc 2023; 16:1953-1977. [PMID: 37484819 PMCID: PMC10361288 DOI: 10.2147/jmdh.s401325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 06/09/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose The main goals of this mixed-methods systematic review are to identify what types of intraoperative stressors for operating room personnel have been reported in collected studies and examine the characteristics of each intraoperative stressor. Methods With a systematic literature search, we retrieved empirical studies examining intraoperative stress published between 2010 and 2020. To synthesize findings, we applied two approaches. First, a textual narrative synthesis was employed to summarize key study information of the selected studies by focusing on surgical platforms and study participants. Second, a thematic synthesis was employed to identify and characterize intraoperative stressors and their subtypes. Results Ninety-four studies were included in the review. Regarding the surgical platforms, the selected studies mainly focused on minimally invasive surgery and few studies examined issues around robotic surgery. Most studies examined intra-operative stress from surgeons' perspectives but rarely considered other clinical personnel such as nurses and anesthetists. Among seven identified stressors, technical factors were the most frequently examined followed by individual, operating room environmental, interpersonal, temporal, patient, and organizational factors. Conclusion By presenting stressors as multifaceted elements affecting collaboration and interaction between multidisciplinary team members in the operating room, we discuss the potential interactions between stressors which should be further investigated to build a safe and efficient environment for operating room personnel.
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Affiliation(s)
- Ahreum Lee
- Samsung Electronics Co. Ltd., Suwon, Gyeonggi-do, Republic of Korea
| | | | - Bin Zheng
- Department of Surgery, University of Alberta, Edmonton, Canada
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Abate LE, Greenberg L. Incivility in medical education: a scoping review. BMC MEDICAL EDUCATION 2023; 23:24. [PMID: 36635675 PMCID: PMC9838055 DOI: 10.1186/s12909-022-03988-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/24/2022] [Indexed: 06/17/2023]
Abstract
Incivility in the workplace, school and political system in the United States has permeated mass and social media in recent years and has also been recognized as a detrimental factor in medical education. In this scoping review, we use the term incivility to encompass a spectrum of behaviors that occur across the continuum of medical education, and which include verbal abuse including rude or dismissive conduct, sexual and racial harassment and discrimination, and sexual and physical assault. We identified research on incivility involving medical students, residents and fellows, and faculty in North America to describe multiple aspects of incivility in medical education settings published since 2000. Our results reinforce that incivility is likely under-reported across the continuum of medical education and also confirmed incidences of incivility involving nursing personnel and patients, not emphasized in previous reviews. The authors suggest a zero-tolerance national policy if this problem is to be resolved.
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Affiliation(s)
- Laura E. Abate
- School of Medicine & Health Sciences, The George Washington University, 2300 Eye St NW, Washington, DC 20037 USA
| | - Larrie Greenberg
- School of Medicine & Health Sciences, The George Washington University, 2300 Eye St NW, Washington, DC 20037 USA
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Keller S, Yule S, Zagarese V, Henrickson Parker S. Predictors and triggers of incivility within healthcare teams: a systematic review of the literature. BMJ Open 2020; 10:e035471. [PMID: 32513884 PMCID: PMC7282335 DOI: 10.1136/bmjopen-2019-035471] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To explore predictors and triggers of incivility in medical teams, defined as behaviours that violate norms of respect but whose intent to harm is ambiguous. DESIGN Systematic literature review of quantitative and qualitative empirical studies. DATA SOURCES Database searches according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline in Medline, CINHAL, PsychInfo, Web of Science and Embase up to January 2020. ELIGIBILITY CRITERIA Original empirical quantitative and qualitative studies focusing on predictors and triggers of incivilities in hospital healthcare teams, excluding psychiatric care. DATA EXTRACTION AND SYNTHESIS Of the 1397 publications screened, 53 were included (44 quantitative and 9 qualitative studies); publication date ranged from 2002 to January 2020. RESULTS Based on the Medical Education Research Study Quality Instrument (MERSQI) scores, the quality of the quantitative studies were relatively low overall (mean MERSQI score of 9.93), but quality of studies increased with publication year (r=0.52; p<0.001). Initiators of incivility were consistently described as having a difficult personality, yet few studies investigated their other characteristics and motivations. Results were mostly inconsistent regarding individual characteristics of targets of incivilities (eg, age, gender, ethnicity), but less experienced healthcare professionals were more exposed to incivility. In most studies, participants reported experiencing incivilities mainly within their own professional discipline (eg, nurse to nurse) rather than across disciplines (eg, physician to nurse). Evidence of specific medical specialties particularly affected by incivility was poor, with surgery as one of the most cited uncivil specialties. Finally, situational and cultural predictors of higher incivility levels included high workload, communication or coordination issues, patient safety concerns, lack of support and poor leadership. CONCLUSIONS Although a wide range of predictors and triggers of incivilities are reported in the literature, identifying characteristics of initiators and the targets of incivilities yielded inconsistent results. The use of diverse and high-quality methods is needed to explore the dynamic nature of situational and cultural triggers of incivility.
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Affiliation(s)
- Sandra Keller
- Center for Surgery and Public Health (CSPH), Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven Yule
- Center for Surgery and Public Health (CSPH), Brigham and Women's Hospital, Boston, Massachusetts, USA
- STRATUS Center for Medical Simulation, Boston, Massachusetts, USA
- Department of surgery, Harvard Medical School, Boston, Massachusetts, USA
- Department of Clinical Surgery, University of Edinburgh, Edinburgh, United Kingdom
| | - Vivian Zagarese
- Department of Psychology, Virginia Tech, Blacksburg, Virginia, USA
| | - Sarah Henrickson Parker
- Department of Psychology, Virginia Tech, Blacksburg, Virginia, USA
- Fralin Biomedical Research Institute (FBRI) at Virginia Tech Carilion, Roanoke, Virginia, USA
- Center for Simulation, Research and Patient Safety, Carilion Clinic, Roanoke, Virginia, USA
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Salehi PP, Jacobs D, Suhail-Sindhu T, Judson BL, Azizzadeh B, Lee YH. Consequences of Medical Hierarchy on Medical Students, Residents, and Medical Education in Otolaryngology. Otolaryngol Head Neck Surg 2020; 163:906-914. [DOI: 10.1177/0194599820926105] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
ObjectiveTo (1) review concepts of medical hierarchy; (2) examine the role of medical hierarchy in medical education and resident training; (3) discuss potential negative impacts of dysfunctional hierarchy in medical and surgical training programs, focusing on otolaryngology; and (4) investigate solutions to these issues.Data SourcesOvid Medline, Embase, GoogleScholar, JSTOR, Google, and article reference lists.Review MethodsA literature search was performed to identify articles relating to the objectives of the study using the aforementioned data sources, with subsequent exclusion of articles believed to be outside the scope of the current work. The search was limited to the past 5 years.ConclusionsTwo types of hierarchies exist: “functional” and “dysfunctional.” While functional medical hierarchies aim to optimize patient care through clinical instruction, dysfunctional hierarchies have been linked to negative impacts by creating learning environments that discourage the voicing of concerns, legitimize trainee mistreatment, and create moral distress through ethical dilemmas. Such an environment endangers patient safety, undermines physician empathy, hampers learning, lowers training satisfaction, and amplifies stress, fatigue, and burnout. On the other hand, functional hierarchies may improve resident education and well-being, as well as patient safety.Implications for PracticeOtolaryngology–head and neck surgery programs ought to work toward creating healthy systems of hierarchy that emphasize collaboration and improvement of workplace climate for trainees and faculty. The goal should be to identify aspects of dysfunctional hierarchy in one’s own environment with the ambition of rebuilding a functional hierarchy where learning, personal health, and patient safety are optimized.
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Affiliation(s)
- Parsa P. Salehi
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniel Jacobs
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Timur Suhail-Sindhu
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Benjamin L. Judson
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Babak Azizzadeh
- Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA
- Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, David Geffen School of Medicine at the University of California–Los Angeles, Los Angeles, California, USA
| | - Yan Ho Lee
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Keller S, Tschan F, Semmer NK, Timm-Holzer E, Zimmermann J, Candinas D, Demartines N, Hübner M, Beldi G. "Disruptive behavior" in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams. PLoS One 2019; 14:e0226437. [PMID: 31830122 PMCID: PMC6907803 DOI: 10.1371/journal.pone.0226437] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team. METHODS AND FINDINGS The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators. CONCLUSIONS Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.
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Affiliation(s)
- Sandra Keller
- Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland
- Virginia Tech, Blacksburg, VA, United States of America
| | - Franziska Tschan
- Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland
| | | | - Eliane Timm-Holzer
- Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland
| | - Jasmin Zimmermann
- Institute of Work and Organizational Psychology, University of Neuchâtel, Neuchâtel, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, University Hospital of Bern, Bern, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Guido Beldi
- Department of Visceral Surgery and Medicine, University Hospital of Bern, Bern, Switzerland
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