How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation.

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.

Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study.

OBJECTIVE: To capture stakeholders' theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice. DESIGN: A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered. SETTING: Nine hospitals in England where robot-assisted surgery is used for colorectal operations. PARTICIPANTS: Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists. RESULTS: Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other's knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential. CONCLUSIONS: We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.

Electronic whiteboards: review of the literature.

Electronic whiteboards are being introduced into hospitals to communicate real-time patient information instantly to staff. This paper provides a preliminary review of the current state of evidence for the effect of electronic whiteboards on care processes and patient outcomes. A literature search was performed for the dates 1996 to 2014 on MEDLINE, EMBASE, IEEE Xplore, Science Direct, and the ACM Digital Library. Thirteen papers, describing 11 studies, meeting the inclusion criteria were identified. The majority of studies took place in the Emergency Department. While studies looked at the impact of electronic whiteboards on the process of care, there is an absence of evidence concerning impact on patient outcomes. There is a need for robust research measuring the impact of electronic whiteboards on inpatient care.

Impact of Robotic Surgery on Decision Making: Perspectives of Surgical Teams.

There has been rapid growth in the purchase of surgical robots in both North America and Europe in recent years. Whilst this technology promises many benefits for patients, the introduction of such a complex interactive system into healthcare practice often results in unintended consequences that are difficult to predict. Decision making by surgeons during an operation is affected by variables including tactile perception, visual perception, motor skill, and instrument complexity, all of which are changed by robotic surgery, yet the impact of robotic surgery on decision making has not been previously studied. Drawing on the approach of realist evaluation, we conducted a multi-site interview study across nine hospitals, interviewing 44 operating room personnel with experience of robotic surgery to gather their perspectives on how robotic surgery impacts surgeon decision making. The findings reveal both potential benefits and challenges of robotic surgery for decision making.

Integration of robotic surgery into routine practice and impacts on communication, collaboration, and decision making: a realist process evaluation protocol.

BACKGROUND: Robotic surgery offers many potential benefits for patients. While an increasing number of healthcare providers are purchasing surgical robots, there are reports that the technology is failing to be introduced into routine practice. Additionally, in robotic surgery, the surgeon is physically separated from the patient and the rest of the team, with the potential to negatively impact teamwork in the operating theatre. The aim of this study is to ascertain: how and under what circumstances robotic surgery is effectively introduced into routine practice; and how and under what circumstances robotic surgery impacts teamwork, communication and decision making, and subsequent patient outcomes. METHODS AND DESIGN: We will undertake a process evaluation alongside a randomised controlled trial comparing laparoscopic and robotic surgery for the curative treatment of rectal cancer. Realist evaluation provides an overall framework for the study. The study will be in three phases. In Phase I, grey literature will be reviewed to identify stakeholders' theories concerning how robotic surgery becomes embedded into surgical practice and its impacts. These theories will be refined and added to through interviews conducted across English hospitals that are using robotic surgery for rectal cancer resection with staff at different levels of the organisation, along with a review of documentation associated with the introduction of robotic surgery. In Phase II, a multi-site case study will be conducted across four English hospitals to test and refine the candidate theories. Data will be collected using multiple methods: the structured observation tool OTAS (Observational Teamwork Assessment for Surgery); video recordings of operations; ethnographic observation; and interviews. In Phase III, interviews will be conducted at the four case sites with staff representing a range of surgical disciplines, to assess the extent to which the results of Phase II are generalisable and to refine the resulting theories to reflect the experience of a broader range of surgical disciplines. The study will provide (i) guidance to healthcare organisations on factors likely to facilitate successful implementation and integration of robotic surgery, and (ii) guidance on how to ensure effective communication and teamwork when undertaking robotic surgery.

Public perception of a range of potential food risks in the United Kingdom.

This study aimed to use a standard questionnaire to obtain a nationally representative sample of opinions on a range of potential food risks. Participants were a national sample of 1182 subjects selected using three different approaches: random and sentinel postal samples and a telephone survey. A modified psychometric questionnaire (the Perceived Food Risk Index) was administered to subjects on three occasions, spanning five time-points. Baseline data collection was undertaken from October to December 1998 (phase 1). The second wave of data collection was undertaken over three time-points in February, April and July 1999 (one-third of respondents to phase 1 at each time-point - data combined as phase 2), and the final phase of data collection was between October and December 1999 (phase 3). Principal components analysis was used to assess the intercorrelations between the items on the questionnaire. Two main components were identified as 'dread' and 'knowledge'. Saturated fats were perceived as the least dreaded and the most known of the potential risks considered, while bovine spongiform encephalopathy and Salmonella were the risks dreaded the most. There was a slight perception that the potential risks had become more known over the year, especially for growth hormones. This study has raised a number of important issues for risk communicators. Despite current policy aimed at reducing fat intake, this will be difficult to achieve at a population level since people are not worried about its impact, yet food safety continues to be a significant concern to the public.

Stakeholder interactions and the development of functional foods.

OBJECTIVE: This paper investigates the roles of the individual stakeholders involved in the development of functional foods and the implications of their actions for public perception of this new food concept. RESULTS: At a time when consumer awareness of the link between diet and health is strong, a new food concept incorporating of a wide spectrum of foods has captured the imagination of the food industry and consumers alike. Functional foods provide a new category of foods that appear to be offering the public the opportunity to achieve a healthy lifestyle with minimal effort. Public perception may determine whether this new food concept is to become the next successful breakthrough in nutritional science or just another marketing gimmick devised by food manufacturers. The paper also addresses issues that arise directly as a result of the emergence of functional foods, such as appropriate legislation in connection to health claims in order to ensure consumer protection and also the lack of clarity in relation to definitions of what constitutes a functional food. CONCLUSION: The paper concludes that functional foods can only reach their maximum potential if the food industry, government and health professionals work together to improve communication between themselves and consumers and also to educate consumers, thereby allowing them to make informed decisions about dietary choices.