Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre
Introduction
Health care professionals, such as surgeons and nurses, work in interprofessional teams. This seemingly obvious fact has crucial importance to patient safety (Kneebone and Fry, 2011), as adverse incidents in surgical operations are often the result of breakdowns in team communication (Aggarwal et al., 2004, Lingard et al., 2004). Research on interprofessional communication in the operating theatre has drawn on different methodologies, including observational rating scales and interviews. Communication problems are frequently reported. According to Lingard et al. (2004), as much as 31% of all communications in the operating theatre could be categorised as failing some way. For example, information provided to colleagues can be inaccurate, delivered too late, or it fails to reach the individuals who need it, leaving issues unresolved until they become critical. In a recent systematic review, Weldon et al. (2013) found that there are not many video-based studies that elaborate on the actual, real-time communication behaviours in the operating theatre.
Communication breakdowns can have many consequences. They can cause delays that compromise the quality of patient care and the management of subsequent operations. As a result, delays in operations can incur substantial costs to hospitals (Wong et al., 2010). When an operation is in progress, surgeons and scrub nurses routinely exchange instruments, and this requires communication and alertness from both parties. Dropping instruments alone has been shown to extend operating time on average by 7.6 min (Khan et al., 2008). However, studies have not elaborated how non-vocal behaviours, such as eye-gaze and hand movements, might contribute to such incidents.
Task-related communication is closely linked to situation awareness. This concept refers to a dynamic process of acquiring information from the immediate environment and responding accordingly to changing situations. There is no single definition of situation awareness but its understanding can be roughly divided into two concerns: the view of awareness primarily as a psychological, cognitive phenomenon (e.g., Endsley, 1995); or as a distributed awareness, involving interactions between people, artefacts, and the environment (Stanton et al., 2006). The widely cited model by Endsley involves three levels: perception of environmental elements in a time and space, understanding their meaning, and using this information to predict events that are likely to happen. Anticipation is an important part of situation awareness, enabling an individual to respond rapidly to changing situations, and potentially preventing adverse incidents from occurring. Interpersonal communication and interaction with artefacts have also been suggested to impact the awareness of what is happening in one's surroundings (Endsley and Jones, 2001). However, some researchers have called for a broader attention to these factors, so as to move the focus from individual cognition to collaboration (Salmon et al., 2008).
Coordination of activities is important for the efficient delivery of surgical operations. Therefore, understanding of situation awareness from the angle of communication becomes relevant. Bromiley (2008) notes how a lack of situation awareness and breakdowns in communication count as human factors that are present in fatal incidents in healthcare, but also in 75% of aviation accidents. A lapse in situation awareness can occur when attention is “fixated” and a professional fails to re-orient and to change a course of action (Bromiley, 2008). As such, situation awareness has particular relevance for scrub nurses. These nurses are “scrubbed up” to work within the sterile zone, and they continuously guard, count, and handle sterile instruments and items, such as swabs and syringes, on the instrument trolley. Their main task is to pass these items to the surgeon, ideally at the precise time of need, so as to avoid any delays in the stages of an operation. Instrument exchange can be cognitively demanding, as the task requires constant vigilance and technical knowledge of the actual operation. Scrub nurses have to remain situationally aware to select the right instrument at the right time (Mitchell and Flin, 2008), and to “both think and remain ‘ahead’ of the surgeon” (Mitchell et al., 2011, p. 822).
Situation awareness has been suggested to be one of the most important non-technical skills that scrub nurses have to master in the operating theatre (Mitchell and Flin, 2008). While such skills have been researched and assessed among surgeons (e.g. Non-Technical Skills for Surgeons [NOTSS], Yule et al., 2008), less is known about how nurses’ non-technical skills relate to situation awareness. Where nurses’ situation awareness has been examined more generally, these studies have tended to draw on cognitive assessments (Wright, 2009) and interviews (Mitchell et al., 2011). While these are important methods, they do not always reveal the details of actual interactions and how people display awareness of the events around them: this is often beyond their awareness. Hence, operating theatre nurses often talk about a “tacit understanding” between colleagues (Gillespie et al., 2010, p. 736).
To address the relative lack of research on theatre nurses’ non-technical skills, The Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) behavioural rating scale (Mitchell et al., 2012) has been recently developed. It focuses on the assessment of non-technical skills, situation awareness, communication and teamwork, and task management among scrub nurses. For example, the core category of situation awareness includes elements of “gathering information”, “recognising and understanding information” and “anticipating”, while two important elements of communication and teamwork are “exchanging information” and “coordinating with others”. Mitchell et al. showed that scrub practitioners have found the rating scale useful in assessing simulated scenarios representing good and bad practice in these core non-technical areas.
Some studies involving anaesthetists, surgeons and perfusionists (Fioratou et al., 2010, Hazlehurst et al., 2007, Parush et al., 2011) have considered situation awareness as a process where verbal communication and interaction with objects are paramount. Hazlehurst et al. show that vocal practices, such as requests and confirmations serve as important resources: A surgeon might ask a perfusionist to adjust the flow of fluids, and the perfusionist vocally confirms this after the adjustment has been done. The spoken clarification informs the surgeon that a transition to a new state has begun, establishing mutual understanding of the situation. Such research suggests that situation awareness can become “visible” through the study of actual interactions.
Section snippets
Researching communication through video research
Video offers an innovative way to examine communication that underpins situation awareness in a greater detail that has been done before. A previous study in an organisational work environment in an organisational work environment has shown that activities of one colleague can unobtrusively encourage others to “notice” critical elements in the environment (Heath et al., 2002). In such cases, awareness is built in and through interactions with others. Through video, real-time activities can be
Methodological framework
The current study is part of a video ethnographic research project examining communication in the operating theatre. The project was centrally concerned with how operating theatre team members communicate using different modes of communication (speech, gaze, movement, gesture, and handling of objects). Video ethnography was used to capture teamwork and communication events as they happened inside the operating theatre, and to record fleeting moments and detailed (vocal and non-vocal) aspects of
Description of two cases
The subsample of two surgical cases (hereafter, Case A and Case B) represents two different contexts for the item exchange. While they involve the same consultant surgeon, the nurses, including the scrub nurse, as well as the assistant surgeons (registrars) are different. In both cases, the scrub nurses had placed their instrument trolleys in different positions. The trolley position was not pre-arranged by the researchers and it was not discussed with the nurses beforehand (rather, the trolley
Discussion
A number of important theoretical, methodological and practical lessons can be drawn from the study. First, the analysis highlights the significance of the role of the scrub nurses’ and surgeons’ bodies in achieving object transfers. Body movements can make a colleague aware of what one is about to do next and consequently, what contingencies this places on the other person (Bezemer et al., 2011, Hindmarsh and Pilnick, 2007). This means that talk is not always needed, but rather attentiveness
Acknowledgements
We would like to thank the Economic and Social Research Council (ESRC) for supporting this research (RES-062-23-3219). We are grateful for the patients who gave their consent for their operations to be filmed for research purposes, and for the operating theatre professionals of the participating NHS Trust in the UK for allowing us to video-record and analyse their interactions.
Conflict of interest: None declared.
Funding: The study arises from a project funded by the Economic and Social Research
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