Emotions and team communication in the operating room: a scoping review

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.

The Cognitive Basis for Human Error and the Best Practices to Reduce Error

A great deal of knowledge exists about how to make health care safer than it is currently. The tools exist but all too often, they are not implemented. All anesthesia providers need to understand what safety best practices are and continue to advocate for them in their workplaces.

Guidelines on human factors in critical situations 2023

OBJECTIVE

To provide guidelines to define the place of human factors in the management of critical situations in anaesthesia and critical care.

DESIGN

A committee of nineteen experts from the SFAR and GFHS learned societies was set up. A policy of declaration of links of interest was applied and respected throughout the guideline-producing process. Likewise, the committee did not benefit from any funding from a company marketing a health product (drug or medical device). The committee followed the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based.

METHODS

We aimed to formulate recommendations according to the GRADE® methodology for four different fields: 1/ communication, 2/ organisation, 3/ working environment and 4/ training. Each question was formulated according to the PICO format (Patients, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology.

RESULTS

The experts' synthesis work and application of the GRADE® method resulted in 21 recommendations. Since the GRADE® method could not be applied in its entirety to all the questions, the guidelines used the SFAR "Recommendations for Professional Practice" A means of secured communication (RPP) format and the recommendations were formulated as expert opinions.

CONCLUSION

Based on strong agreement between experts, we were able to produce 21 recommendations to guide human factors in critical situations.

A tool to assess nontechnical skills of perfusionists in the cardiac operating room

OBJECTIVES

This study aimed to develop the Perfusionists' Intraoperative Non-Technical Skills tool, specifically to the perfusionists' context, and test its inter-rater reliability.

METHODS

An expert panel was convened to review existing surgical nontechnical skills taxonomies and develop the Perfusionists' Intraoperative Non-Technical Skills tool. During a workshop held at a national meeting, perfusionists completed the Perfusionists' Intraoperative Non-Technical Skills ratings after watching 4 videos displaying simulated cardiac operations. Two videos showed "good performance," and 2 videos showed "poor performance." Inter-rater reliability analysis was performed and intraclass correlation coefficient was reported.

RESULTS

The final version of the Perfusionists' Intraoperative Non-Technical Skills taxonomy contains 4 behavioral categories (decision making, situation awareness, task management and leadership, teamwork and communication) with 4 behavioral elements each. Categories and elements are rated using an 8-point Likert scale ranging from 0.5 to 4.0. A total of 60 perfusionist raters were included and the comparison between rating distribution on "poor performance" and "good performance" videos yielded a statistically significant difference between groups, with a P value less than .001. A similar difference was found in all behavioral categories and elements. Reliability analysis showed moderate inter-rater reliability across overall ratings (intraclass correlation coefficient, 0.735; 95% confidence interval, 0.674-0.796; P < .001). Similar inter-rater reliability was found when raters were stratified by experience level.

CONCLUSIONS

The Perfusionists' Intraoperative Non-Technical Skills tool presented moderate inter-rater reliability among perfusionists with varied levels of experience. This tool can be used to train and assess perfusionists in relevant nontechnical skills, with the potential to enhance safety and improve surgical outcomes.

Ethical and Legal Considerations for Recording in the Operating Room: A Systematic Review

INTRODUCTION

The integration of high-resolution video into surgical practice has fostered widespread interest in capturing surgical video recordings for the purposes of patient care, medical training, quality improvement, and documentation. The capture, analysis, and storing of such recordings inherently impact operating room (OR) activities and introduce potential harms to patients as well as members of the surgical team, which can be analyzed from both ethical and legal perspectives.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines, a systematic literature search of PubMed was conducted. The citations of included articles were then reviewed to find any articles not captured by our initial search.

RESULTS

62 Articles were included in the review (52 from PubMed search and 10 from citation review). Prevalent key issues in the literature at present include privacy, consent, ownership, legal use and discoverability, editing, data security, and recording's impact on the surgical team.

CONCLUSIONS

This review aims to spark proactive discussions of the ethical and legal implications of recording in the OR, which will guide transformation as the medical field adapts to new and innovative technologies without compromising its ideals or patient care.

Objective Measures of Surgeon Non-Technical Skills in Surgery: A Scoping Review

OBJECTIVE

The purpose of this study was to identify, synthesize, and discuss objective behavioral or physiological metrics of surgeons' nontechnical skills (NTS) in the literature.

BACKGROUND

NTS, or interpersonal or cognitive skills, have been identified to contribute to safe and efficient surgical performance; however, current assessments are subjective, checklist-based tools. Intraoperative skill evaluation, such as technical skills, has been previously utilized as an objective measure to address such limitations.

METHODS

Five databases in engineering, behavioral science, and medicine were searched following PRISMA reporting guidelines. Eligibility criteria included studies with NTS objective measurements, surgeons, and took place within simulated or live operations.

RESULTS

Twenty-three articles were included in this review. Objective metrics included communication metrics and measures from physiological responses such as changes in brain activation and motion of the eye. Frequencies of content-coded communication in surgery were utilized in 16 studies and were associated with not only the communication construct but also cognitive constructs of situation awareness and decision making. This indicates the underlying importance of communication in evaluating the NTS constructs. To synthesize the scoped literature, a framework based on the one-way communication model was used to map the objective measures to NTS constructs.

CONCLUSION

Objective NTS measurement of surgeons is still preliminary, and future work on leveraging objective metrics in parallel with current assessment tools is needed.

APPLICATION

Findings from this work identify objective NTS metrics for measurement applications in a surgical environment.

System Factors Affecting Intraoperative Risk and Resilience: Applying a Novel Integrated Approach to Study Surgical Performance and Patient Safety

OBJECTIVE

To identify and categorize system factors in complex laparoscopic surgery that have the potential to either threaten patient safety or support system resilience.

BACKGROUND

The operating room is a uniquely complex sociotechnical work system wherein surgical successes prevail despite pervasive safety threats. Holistically characterizing intraoperative factors that thus support system resilience in addition to those that threaten patient safety using contextual methodologies is critical for optimizing surgical safety overall.

METHOD

In this prospective descriptive interdisciplinary study, 19 audio/video recordings of complex laparoscopic general surgical procedures were directly observed and transcribed. Using a qualitative systems-based approach, intraoperative human factors with the potential to impact patient safety, either as a safety threat or as a support for resilience, were identified. Adverse events were further assessed for shared threats and supports. Data collection was guided by the Systems Engineering Initiative for Patient Safety 2.0 work system model.

RESULTS

A total of 1083 relevant observations were made over 39.8 hours of operative time, enabling the identification of 79 distinct safety threats and 67 resilience supports within the surgical system. Safety threats associated with the physical environment, tasks, organization, and equipment were prevalent and observed in equal measure, whereas supports for resilience were predominantly attributed to clinician behaviors, including proactive team management and skills coaching. Two subclinical adverse events were identified; shared safety threats included suboptimal technology design, whereas shared resilience supports included calm clinician behavior and redundant intraoperative resourcing.

CONCLUSIONS

Safety threats and resilience supports were found to be systematic in the surgical setting. Identified safety threats should be prioritized for remediation, and clinician behaviors that contribute to fostering resilience should be valued and protected.

How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis

OBJECTIVES

To investigate the relationship between teamwork and clinical performance and potential moderating variables of this relationship.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed was searched in June 2018 without a limit on the date of publication. Additional literature was selected through a manual backward search of relevant reviews, manual backward and forward search of studies included in the meta-analysis and contacting of selected authors via email.

ELIGIBILITY CRITERIA

Studies were included if they reported a relationship between a teamwork process (eg, coordination, non-technical skills) and a performance measure (eg, checklist based expert rating, errors) in an acute care setting.

DATA EXTRACTION AND SYNTHESIS

Moderator variables (ie, professional composition, team familiarity, average team size, task type, patient realism and type of performance measure) were coded and random-effect models were estimated. Two investigators independently extracted information on study characteristics in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The review identified 2002 articles of which 31 were included in the meta-analysis comprising 1390 teams. The sample-sized weighted mean correlation was r=0.28 (corresponding to an OR of 2.8), indicating that teamwork is positively related to performance. The test of moderators was not significant, suggesting that the examined factors did not influence the average effect of teamwork on performance.

CONCLUSION

Teamwork has a medium-sized effect on performance. The analysis of moderators illustrated that teamwork relates to performance regardless of characteristics of the team or task. Therefore, healthcare organisations should recognise the value of teamwork and emphasise approaches that maintain and improve teamwork for the benefit of their patients.

Developing a Quality Standard for Verbal Communication During CABG Procedures

Verbal communication during coronary artery bypass graft (CABG) procedures is essential for safe and efficient cardiac surgery, yet sensitive to failure due to a current lack of standardization. The goal of this study was to improve communication during CABG by identifying critical items in verbal interaction between surgeons, anesthetists, and perfusionists. Based on 6 video recordings, a list was assembled containing items of communication in CABG procedures. Personal interviews and a consecutive focus group meeting with surgeons, anesthetists, and perfusionists revealed which of these items were considered critical. Afterward, the recordings were systematically analyzed on the communication of these critical items. Practitioners considered 64 items to be critical to verbally communicate for safe CABG surgery. On average, these critical items were verbalized in 4.4 out of 6 recorded CABGs. Observations also show that the surgical subteam is the most verbally active subteam and the initiator of the majority of all exchanges. The exchange type involved was mainly "direction" and "status." The majority of communication during critical events is between 2 subteams and occurs in the form of call-back loops. Over half of the call-backs are substantive and communication is rarely directed at a specific team member by name. In this study, a list was developed containing 64 items that practitioners unanimously considered critical to verbalize during a CABG procedure. It forms the foundation of a quality standard for verbal communication during cardiopulmonary bypass (CPB) and can increase safety and efficiency of cardiac surgery.

The impact of team characteristics and context on team communication: An integrative literature review

Many studies on teams report measures of team communication; however, these studies vary widely in terms of the team characteristics, situations, and tasks studied making it difficult to understand impacts on team communication more generally. The objective of this review is systematically summarize relationships between measures of team communication and team characteristics and situational contexts. A literature review was conducted searching in four electronic databases (PsycINFO, MEDLINE, Ergonomics Abstracts, and SocINDEX). Additional studies were identified by cross-referencing. Articles included for final review had reported at least one team communication measure associated with some team and/or context dimension. Ninety-nine of 727 articles met the inclusion criteria. Data extracted from articles included characteristics of the studies and teams and the nature of each of the reported team and/or context dimensions-team communication properties relationships. Some dimensions (job role, situational stressors, training strategies, cognitive artifacts, and communication media) were found to be consistently linked to changes in team communication. A synthesized diagram that describes the possible associations between eleven team and context dimensions and nine team communication measures is provided along with research needs.

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.

The Loud Surgeon Behind the Console: Understanding Team Activities During Robot-Assisted Surgery

OBJECTIVES

To design a data collection methodology to capture team activities during robot-assisted surgery (RAS) (team communications, surgical flow, and procedural interruptions), and use relevant disciplines of Industrial Engineering and Human Factors Engineering to uncover key issues impeding surgical flow and guide evidence-based strategic changes to enhance surgical performance and improve outcomes.

DESIGN

Field study, to determine the feasibility of the proposed methodology.

SETTING

Recording the operating room (OR) environment during robot-assisted surgeries (RAS). The data collection system included recordings from the console and 3 aerial cameras, in addition to 8 lapel microphones (1 for each OR team member). Questionnaires on team familiarity and cognitive load were collected.

PARTICIPANTS

In all, 37 patients and 89 OR staff members have consented to participate in the study.

RESULTS

Overall, 37 RAS procedures were recorded (130 console hours). A pilot procedure was evaluated in detail. We were able to characterize team communications in terms of flow, mode, topic, and form. Surgical flow was evaluated in terms of duration, location, personnel involved, purpose, and if movements were avoidable or not. Procedural interruptions were characterized according to their duration, cause, mode of communication, and personnel involved.

CONCLUSION

This methodology allowed for the capture of a wide variety of team activities during RAS that would serve as a solid platform to improve nontechnical aspects of RAS.

Network measures for characterising team adaptation processes

The aim of this study was to advance the conceptualisation of team adaptation by applying social network analysis (SNA) measures in a field study of a paediatric cardiac surgical team adapting to changes in task complexity and ongoing dynamic complexity. Forty surgical procedures were observed by trained human factors researchers, and communication processes amongst team members were recorded. Focusing on who talked to whom, team communication structures, in response to changing task demands, were characterised by various network measures. Results showed that in complex procedures, the communication patterns were more decentralised and flatter. Also, in critical transition phases of the procedure, communication was characterised by higher information sharing and participation. We discuss implications for team adaptation theory and teamwork observation methods.

PRACTITIONER SUMMARY

The reasons for this study were to advance our conceptualisation of team adaptation processes and to further quantify team observation methods. We found that the surgical team studied adapted to complexity of surgical procedures by adopting flatter communication patterns. We quantified team observation methods by applying SNA techniques.

Assessing scrub practitioner non-technical skills: a literature review

A review by Catchpole et al (2009) into the causes and types of harm experienced by the surgical patient emphasised the high risk nature of the perioperative period. Investigations into recent failures at NHS organisations have emphasised the relevance of non-technical skills education in improving clinical performance and patient outcomes. However, scrub practitioner non-technical skills are often developed on a tacit basis, making assessment of performance difficult. This literature review identifies strategies that facilitate assessment of non-technical skills during surgery. Recommendations are made that will assist scrub practitioners in using a validated scrub practitioner non-technical skills assessment framework reliably.

Assessing neurosurgical non-technical skills: an exploratory study of a new behavioural marker system

RATIONALE, AIMS AND OBJECTIVES

The management of non-technical skills is a major factor affecting teamwork quality and patient safety. This article presents a behavioural marker system for assessing neurosurgical non-technical skills (BMS-NNTS). We tested the BMS during deep brain stimulation surgery.

METHOD

We developed the BMS in three stages. First, we drew up a provisional assessment tool based on the literature and observation tools developed for other surgical specialties. We then analysed videos made in an operating room (OR) during deep brain stimulation operations in order to ensure there were no significant omissions from the skills list. Finally, we used five videos of operations to identify the behavioural markers of non-technical skills in verbal communications.

RESULTS

Analyses of more than six hours of observations revealed 3515 behaviours from which we determined the neurosurgeon's non-technical skills behaviour pattern. The neurosurgeon frequently engaged in explicit coordination, situation awareness and leadership behaviours. In addition, the neurosurgeon's behaviours differed according to the stage of the operation and the OR staff members with whom she was communicating.

CONCLUSIONS

Our behavioural marker system provides a structured approach to assessing non-technical skills in the field of neurosurgery. It can also be transferred to other surgical specialties and used in surgeon training curricula.

Read-back improves information transfer in simulated clinical crises

BACKGROUND

Safe and effective healthcare is frustrated by failures in communication. Repeating back important information (read-back) is thought to enhance the effectiveness of communication across many industries. However, formal communication protocols are uncommon in healthcare teams.

AIMS

We aimed to quantify the effect of read-back on the transfer of information between members of a healthcare team during a simulated clinical crisis. We hypothesised that reading back information provided by other team members would result in better knowledge of that information by the receiver than verbal response without read-back or no verbal response.

METHOD

Postanaesthesia care unit nurses and anaesthetic assistants were given clinically relevant items of information at the start of 88 simulations. A clinical crisis prompted calling an anaesthetist, with no prior knowledge of the patient. Using video recordings of the simulations, we noted each time a piece of information was mentioned to the anaesthetist. Their response was coded as read-back, verbal response without read-back or no verbal response.

RESULTS

If the anaesthetists read back the item of information, or otherwise verbally responded, they were, respectively, 8.27 (p<0.001) or 3.16 (p=0.03) times more likely to know the information compared with no verbal response.

CONCLUSIONS

Our results suggest that training healthcare teams to use read-back techniques could increase information transfer between team members with the potential for improved patient safety. More work is needed to confirm these findings.