A Surgical Team Simulation to Improve Teamwork and Communication across Two Continents: ViSIOT Proof-of-Concept Study.

BACKGROUND: Team communication in operating rooms is problematic worldwide, and can negatively impact patient safety. Although initiatives such as the World Health Organization's Surgical Safety Checklist have been introduced to improve communication, patient safety continues to be compromised globally, warranting the development of new interventions. Video-based social science methods have contributed to the study of communication in UK ORs through actual observations of surgical teams in practice. Drawing on this, the authors have developed a surgical team simulation-training model [Video-Supported Simulation of Interactions in the Operating Theatre (ViSIOT)]. A proof-of-concept study was conducted in the UK and USA to assess if the ViSIOT simulation-training has applicability and acceptability beyond the UK. METHODS: ViSIOT training was conducted at two simulation centers in the UK and USA over a 10-month period. All surgical team participants completed a questionnaire (that assessed design, education, satisfaction, and self-confidence in relation to the training). Descriptive and inferential statistics were performed for the quantitative data and thematic analysis was conducted for the qualitative data. RESULTS: There was strong agreement from all participants in terms of their perception of the course across all sub-sections measured. Nine themes from the qualitative data were identified. The two countries shared most themes, however, some emerged that were unique to each country. CONCLUSIONS: Practical developments in the course design, technology, and recruitment were identified. Evidence of the course applicability in the USA provides further affirmation of the universal need for team communication training within ORs. Further studies are required to assess its effectiveness in improving communication in OR practice.

Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study.

BACKGROUND: One challenge identified in the Surgical Safety Checklist literature is the inconsistent participation of operating teams in the safety checks. Less is known about how teams move from preparatory activities into a huddle, and how communication underpins this gathering. The objective of this study is to examine the ways of mobilising teams and the level of participation in the safety checks. METHODS: Team participation in time-out and sign-out was examined from a video corpus of 20 elective surgical operations. Teams included surgeons, nurses and anaesthetists in a UK teaching hospital, scheduled to work in the operations observed. Qualitative video analysis of team participation was adapted from the study of social interaction. RESULTS: The key aspects of team mobilisation were the timing of the checklist, the distribution of personnel in the theatre and the instigation practices used. These were interlinked in bringing about the participation outcomes, the number of people huddling up for time-out and sign-out. Timing seemed appropriate when most personnel were present in the theatre suite; poor timing was marked by personnel dispersed through the theatre. Participation could be managed using the instigation practices, which included or excluded participation within teams. The factors hindering full-team participation at time-out and sign-out were the overlapping (eg, anaesthetic and nursing) responsibilities and the use of exclusive instigation practices. CONCLUSIONS: The implementation of the Surgical Safety Checklist represents a global concern in patient safety research. Yet how teams huddle for the checks has to be acknowledged as an issue in its own right. Appropriate mobilisation practices can help bringing fuller teams together, which has direct relevance to team training.

The Sally-Anne test: an interactional analysis of a dyadic assessment.

BACKGROUND: The Sally-Anne test has been extensively used to examine children's theory of mind understanding. Many task-related factors have been suggested to impact children's performance on this test. Yet little is known about the interactional aspects of such dyadic assessment situations that might contribute to the ways in which children respond to the test questions. AIMS: To examine the interactional factors contributing to the performance of two children in the Sally-Anne test. To identify the interactional practices used by the tester administering the task and to describe how interactional features can pose challenges in the critical belief and reality questions for both the tester and the testee. METHODS & PROCEDURES: The Sally-Anne test was carried out as part of a project examining children's interactions in a technology-enhanced environment. The present study uses video recordings of two children with communication disorders (one with a current diagnosis of autism spectrum disorder [ASD]) and an adult tester. We draw on a multimodal approach to conversation analysis (CA) to examine the sequential organization of the test questions and answers. OUTCOMES & RESULTS: The children drew on diverse resources when producing responses to the test questions: responding verbally, pointing or manually handling objects. The tester treated these responses differently depending on how they were produced. When the child pointed at an object and verbally indicated their response, the tester moved on to the next question apparently accepting the child's answer. When the child manually handled an object or produced a quiet verbal response, the tester repeated the question indicating that the child's actions did not constitute an adequate response to a test question. In response to this, both children modified or changed their previous responses. Through monitoring each other, the tester and the child produced actions highly responsive to the features of each other's conduct, which underpinned the conduct of the test itself. CONCLUSIONS & IMPLICATIONS: Children's responses in the test might not be solely indicative of socio-cognitive capacities but also show orientation to interactional nuances. The study proposes that children can demonstrate diverse ways of responding to questions, yet testers may treat these as test-irrelevant behaviours if they do not correspond to the scoring criteria. A video-based CA study can broaden our understanding of children's pragmatic competencies in responsiveness that may not always embody an expected form. This can have implications for the development of future assessment tasks and revision of existing scoring practices.

Unsettled teamwork: communication and learning in the operating theatres of an urban hospital.

AIM: To explore the unsettling effects of increased mobility of nurses, surgeons and other healthcare professionals on communication and learning in the operating theatre. BACKGROUND: Increasingly, healthcare professionals step in and out of newly formed transient teams and work with colleagues they have not met before, unsettling previously relatively stable team work based on shared, local knowledge accumulated over significant periods of close collaboration. DESIGN: An ethnographic case study was conducted of the operating theatre department of a major teaching hospital in London. METHOD: Video recordings were made of 20 operations, involving different teams. The recordings were systematically reviewed and coded. Instances where difficulties arose in the communication between scrub nurse and surgeons were identified and subjected to detailed, interactional analysis. FINDINGS: Instrument requests frequently prompted clarification from the scrub nurse (e.g. 'Sorry, what did you want?'). Such requests were either followed by a relatively elaborate clarification, designed to maximize learning opportunities, or a by a relatively minimal clarification, designed to achieve the immediate task at hand. CONCLUSIONS: Significant variation exists in the degree of support given to scrub nurses requesting clarification. Some surgeons experience such requests as disruptions, while others treat them as opportunities to build shared knowledge.

Music and communication in the operating theatre.

AIMS: To observe the extent and the detail with which playing music can impact on communication in the operating theatre. BACKGROUND: According to the cited sources, music is played in 53-72% of surgical operations performed. Noise levels in the operating theatre already exceed World Health Organisation recommendations. There is currently a divide in opinions on the playing of music in operating theatres, with few studies conducted and no policies or guidance provided. DESIGN: An ethnographic observational study of teamwork in operating theatres through video recordings. Quantitative and qualitative data analysis approaches were used. METHODS: This study was conducted between 2012-2013 in the UK. Video recordings of 20 operations over six months in two operating theatres were captured. The recordings were divided into music and non-music playing cases. Each case was logged using a request/response sequence identified through interactional analysis. Statistical analysis, using a χ(2) , explored the difference between the proportion of request repetitions and whether music was playing or not. Further interactional analysis was conducted for each request repetition. RESULTS: Request/response observations (N = 5203) were documented. A chi-square test revealed that repeated requests were five times more likely to occur in cases that played music than those that did not. A repeated request can add 4-68 seconds each to operation time and increased tensions due to frustration at ineffective communication. CONCLUSIONS: Music played in the operating theatre can interfere with team communication, yet is seldom recognized as a potential safety hazard. Decisions around whether music is played and around the choice of music and its volume, are determined largely by surgeons. Frank discussions between clinicians, managers, patients and governing bodies should be encouraged for recommendations and guidance to be developed.

Nurse-surgeon object transfer: video analysis of communication and situation awareness in the operating theatre.

BACKGROUND: One of the most central collaborative tasks during surgical operations is the passing of objects, including instruments. Little is known about how nurses and surgeons achieve this. The aim of the present study was to explore what factors affect this routine-like task, resulting in fast or slow transfer of objects. METHODS: A qualitative video study, informed by an observational ethnographic approach, was conducted in a major teaching hospital in the UK. A total of 20 general surgical operations were observed. In total, approximately 68 h of video data have been reviewed. A subsample of 225 min has been analysed in detail using interactional video-analysis developed within the social sciences. RESULTS: Two factors affecting object transfer were observed: (1) relative instrument trolley position and (2) alignment. The scrub nurse's instrument trolley position (close to vs. further back from the surgeon) and alignment (gaze direction) impacts on the communication with the surgeon, and consequently, on the speed of object transfer. When the scrub nurse was standing close to the surgeon, and "converged" to follow the surgeon's movements, the transfer occurred more seamlessly and faster (<1.0 s) than when the scrub nurse was standing further back from the surgeon and did not follow the surgeon's movements (>1.0 s). CONCLUSIONS: The smoothness of object transfer can be improved by adjusting the scrub nurse's instrument trolley position, enabling a better monitoring of surgeon's bodily conduct and affording early orientation (awareness) to an upcoming request (changing situation). Object transfer is facilitated by the surgeon's embodied practices, which can elicit the nurse's attention to the request and, as a response, maximise a faster object transfer. A simple intervention to highlight the significance of these factors could improve communication in the operating theatre.

Gearing up to a new activity: how teachers use object adjustments to manage the attention of children with autism.

Children with autism have characteristic difficulties with joint attention. In educational settings, this can present a challenge when directing a child's attention to new objects and activities. Drawing on videotaped interactions between teachers and two children with autism recorded in Finland, we use conversation analysis to examine how teachers manage such transitions during one-to-one teaching. We show how adjusting material objects can be used to manage the child's engagement and how these adjustments can escalate into more conspicuous actions so as to direct the child's attention. Rather than examining participants' use of communicational objects, we are instead concerned with practices that use task-related objects. We thereby offer an empirically grounded account of the interactional practices involved in achieving joint attention through the objects themselves.