Speech Communication Interference in the Operating Room.

INTRODUCTION: Operating room communication is frequently disrupted, raising safety concerns. We used a Speech Interference Instrument to measure the frequency, impact, and causes of speech communication interference (SCI) events. METHODS: In this prospective study, we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as "group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange." We performed supplemental observations, focused on conducting postsurgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews. RESULTS: The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending (50.5%), circulating nurse (44.6%), resident (44.6%), or scrub tech (42.7%). The majority (82.1%) of SCI events occurred during another patient-related task. 17.5% occurred at a critical moment. 27.2% of SCI events were not acknowledged or repeated and the message was lost. Including the supplemental observations, 97.0% of SCI events caused a delay (mean 5 s). Inter-rater reliability, calculated by Gwet's AC1 was 0.87-0.98. Postsurgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g., suction), conversations, or multitasking (e.g., using the electronic health record). Successful strategies included repetition or deferment of the request until competing tasks were complete. CONCLUSIONS: Communication interference may have patient safety implications that arise from conflicts with other case-related tasks, machine noises, and other conversations. Reorganization of workflow, tasks, and communication behaviors could reduce miscommunication and improve surgical safety and efficiency.

Human-Caused Sound Distractors and their Impact on Operating Room Team Function.

BACKGROUND: Patient safety in the Operating Room (OR) depends on unobstructed team communication. Yet the typical OR is loud, containing numerous sounds from surgical machinery overlayed with human-caused sounds. Our objective was to compare machine vs human-caused sounds for their loudness and distraction, and potential impact on team communication. METHODS: After surveying OR staff about sounds that interfere with job performance and team communication, we recorded 19 machine and 48 human-caused sounds measuring their acoustical intensity. We compared peak measures of machine vs human-caused sound loudness, using Student's t-test. We observed the effect of these sounds on OR staff in 59 live surgeries, rating level of interference with team function. We visually depicted competing sounds through a spectral analysis. RESULTS: The survey response rate was 62.8%. 93% of respondents indicated that OR noise, especially human-caused sounds such as irrelevant conversations, interfere with team communication, hearing, and focus. OR peak decibel levels ranged from 56.8 dB (surgical packaging) to 105.0 dB (kicked metal stepstool). Human-caused sounds were comparable to machine-caused sounds in terms of mean peak dB levels (77.0 versus 73.8 dB, p = 0.32), yet were rated as more interfering with surgical team function. The spectral analysis illustrated both machine and human-caused sound sources obscuring the surgeon's instructions. CONCLUSIONS: Avoidable human-caused sounds are a major source of disruption in the OR and interfere with communication and job performance. We recommend surgical team training to minimize these distractions.

The Impact of Facial Personal Protective Equipment on Speech Intensity.

IMPORTANCE: Facial personal protective equipment (FPPE) filters small particles in the operating room (OR) but also affects speech production, diminishing the effective transfer of information among OR team members. OBJECTIVE: The aim of the study is to assess the attenuating effects of different combinations of layered FPPE on speech intensity, including potential differences in the effect of talkers with varying backgrounds and speaking volumes. STUDY DESIGN: We recruited 30 speakers from health and nonhealth occupations with English as either their first or second language. All participants spoke unmasked, at varying voice levels into a portable Zoom H4n device 12 inches from the microphone. These no-mask recordings were played from a Styrofoam head, fitted with 7 combinations of FPPE commonly worn in the COVID-19 era, with the attenuated signals assessed for digital average signal levels. We submitted these attenuation values to an omnibus mixed analysis of variance and performed a spectral analysis on signal attenuation stratified by typical speech frequency bands. RESULTS: Signal attenuation was strongly determined by FPPE combination, regardless of talker sex, first language, and occupation ( P < 0.01, η 2p = 0.881). The effects of vocal output were also significant ( P < 0.01, η 2p = 0.881). Soft talkers experienced particularly high attenuation at frequency bands higher than 2,000 Hz. The signal of the softest talkers, when asked to speak loudly, was similar to the loud talkers' signal. CONCLUSIONS: Layered FPPE in the OR protects the surgical team from small particle exposure but may increase communication failures. Our data can help OR staff choose FPPE and alter their vocal volume accordingly.

Self-Care for Advanced Practice Nursing Students in Rural Primary Care.

BACKGROUND: Advanced practice RNs (APRNs) working in rural primary care provide a spectrum of health care needs that can lead to professional burnout. As a preventative for burnout, the Institute of Medicine developed a strategy focused on self-care. Understanding the importance of self-care as a preventive for building professional resilience to manage workplace stressors during students' academic years may improve retention. METHOD: Twenty-two APRN students participated in a rural primary care immersion course with a specific component on self-care. Preand postsurveys, student journaling, class discussions, and a posttraining focus group were used to assess students' progress. RESULTS: Students reported strengthening patient and team relationships, enhanced interpersonal communication, and increased self-awareness of stressors for managing their emotions. These self-imposed processes improved student confidence, job satisfaction, and workplace resilience. CONCLUSION: Heath-promoting behaviors via self-care during APRN students' formal education may assist them in their clinical practice as rural primary care providers. [J Nurs Educ. 2022;61(4):187-191.].

Mental 3D Visualization: Building Surgical Resilience for Performing High-Risk Procedures.

OBJECTIVE: Psychological resilience has been studied in several demanding professions, including the military and competitive sports, yet specific strategies for managing stress are not commonly addressed during surgical training. The objective of this study was to investigate how surgeons view performance under pressure during high-risk surgical steps. DESIGN: Using constructivist grounded theory, we conducted 12 individual semi-structured interviews with a theoretical sample teaching surgeons, representing 10 different specialties and a range of experience. We drew on Luthar's concept of resilience as positive adaptation, an active and flexible process in which critical choices are made in stressful situations. We asked about both protective and vulnerability factors contributing to resilience in high-risk surgery. We coded transcripts, transforming each category of codes into a visual schematic highlighting our findings related to performance under pressure and resilience, which we transformed into a conceptual model. SETTING: Truman Medical Center, Kansas City, MO, tertiary hospital. PARTICIPANTS: Twelve teaching surgeons from 10 different surgical specialties. RESULTS: Mental 3D visualization is necessary for proper preoperative planning, enacting contingency plans in the face of intra-operative challenges, and managing emotions during high-risk surgery. Each of these factors informs staying calm under pressure and is necessary for building long-term surgical resilience. Negotiating challenges in high-risk surgery is contingent upon adapting to risk developed over time through surgical experience, mental 3D visualization, intentionality, and self-reflection. CONCLUSIONS: Mental 3D visualization informs processes for staying calm under pressure and is essential for building long-term surgical resilience. We recommend that residency curricula offer progressive education on mental 3D visualization and foster intraoperative environments that promote adapting to risk.

Absence or presence: Silent discourse in the operating room and impact on surgical team action.

BACKGROUND: Our objective was to examine the influence of silence on team action in the operating room. METHODS: We conducted a constructed grounded theory study with semi-structured interviews with 25 interprofessional surgical team members. Using a framework of silence as communication and performance, transcripts were iteratively team-coded to develop themes and a conceptual model. RESULTS: OR silence is expressed verbally and nonverbally. Two contexts of silence were identified: homogenous as collective action, and disparate, as disengagement. Complex and dynamic, two primary themes emerged, Power that often shuts down communication, and Focus during critical moments. Five additional sub-themes included critical moments, respect, self-reflection, personal preference, and, bad mood. CONCLUSION: OR silence is not an absence of communication and requires a response. Whether homogenous through cohesiveness, or desperate as a solitary act, OR silence is a call to action. Examining silence as a part discourse has important implications on surgical team function.

Preparing Nurse Practitioner Students to Practice in Rural Primary Care.

BACKGROUND: Gaps remain in rural primary care. To fill this gap, nurse practioner (NP) graduates may need additional training using a rural-specific curriculum framework to be ready to practice in rural primary care. METHOD: Ten NP students participated in a 16-week rural immersion. Preand postsurveys, online journaling, self-guided testing, simulation events, and postcourse focus groups were used to evaluate student progress using directed content analysis to identify key themes and to verify, organize, and categorize the collected data. RESULTS: Students reported gains in rural culture competence, increased skills in health literacy and patient advocacy, improved communication and negotiating ethical issues with patients, and increased awareness of challenges in rural health care and the importance of resilience. CONCLUSION: An immersion learning experience with targeted didactic content and clinical practicum in rural primary care can help to enhance NP students' confidence and technical abilities for providing optimal rural primary care. [J Nurs Educ. 2020;59(10):581-584.].