"Enhanced communication is effective, less costly, and time efficient. Errors decrease when effective, relevant information is shared." This comment, by one of the participants in OR Nurse 2010's "The Skinny on OR Communication Techniques" survey, sums up the gains of effective communication.
Most nurses would agree communication is a key part of patient safety. Perioperative nurses now have several standardized communication tools including Situation-Background-Assessment-Recommendation (SBAR), preoperative briefing, World Health Organization (WHO) checklist, and Universal Protocol (see About the communication techniques).
At OR Nurse 2010, we wondered how many perioperative nurses were familiar with these tools, how often they were used, their ease of use, and their effectiveness. To answer those and other questions, we conducted an online survey from April 2010 to June 2010.
More than 500 (578) of you responded to the survey (see About the respondents and Perioperative nursing experience). Although most, but far from all, nurses know about the four communication tools, they're not universally integrated into practice. Fewer than a quarter (22%) of nurses say standardized communication techniques are performed 100% of the time in their facility, 36% report they're performed 75% to 99% of the time, and 14% "never" use any of the techniques.
Even the numbers of those who use the tools may be falsely high. "If you looked at what respondents actually did in practice, the numbers would likely be lower," says Christine Goeschel, RN, MPA, MPS, ScD, director of patient safety and quality initiatives and manager of operations at Johns Hopkins Quality and Safety Research Group in Baltimore. Goeschel, who works with hospitals implementing checklists and other quality initiatives, says the reason is reporting bias—people tend to believe and report that they adhere to guidelines or recommended behaviors more often than they actually do.
Many facilities still struggle with implementing these tools, encountering resistance from surgeons and staff. And even though most nurses say the tools are helpful and effective ("It is great practice that everyone in the OR stop [before making the incision] and remember why we are all there and what we're about to do," says one nurse), many find them too cumbersome. "So much has been added to the checklist of things in the time-out that it's really redundant," reports one respondent. "There are feelings that this is one more ‘thing’ to remember to do. This creates frustration within the team."
Here's a closer look at the results.
Universal Protocol leads the way
The two communication tools that most nurses have heard of are Universal Protocol (88%) and SBAR (81%). "The Universal Protocol has been the most effective communication tool for us in preventing wrong site surgery," notes one nurse.
Nearly two thirds of respondents are familiar with preoperative briefings (64%) and the WHO checklist (62%), and more than a third (39%) listed "other communication techniques."
Nurses with 21 or more years of experience are the most familiar with all four communication techniques, with the next highest being those with 16 to 20 years of experience. New nurses (0 to 5 years) are most familiar with SBAR and Universal Protocol. (see Familiarity with communication techniques by years of experience).
About 58% of nurses report that a standardized communication technique is used in their OR 75% to 100% of the time (see Frequency that SBAR or other standardized communication techniques are used in the OR.) Only 22% use one of the techniques 100% of the time and 14% don't use any technique. Managers and administrators were slightly more likely than staff nurses (62.2% versus 57.6%) to report that communication techniques are used 75% to 100% of the time.
Frequency of use varied by communication type (see Frequency of standardized communication use in the OR.) For example, 54% of facilities don't use the WHO checklist and 21% use it all the time, but 7.5% don't use Universal Protocol and 58% use it 100% of the time.
Only slightly more than a quarter (26.1%) of facilities use sponge-tracking devices, perhaps because of the expense of RFID systems and that the technology is relatively new (see Facilities using a sponge-tracking device.) However, the inexpensive, low-tech whiteboard is common in ORs, with 71.6% of respondents reporting they use one (see Facilities using a whiteboard for patient data.)
"A white board lets everyone see the information instead of the nurse having to dig through the chart for it," says Carol Giese, BSN, RN, CNOR, education coordinator for surgical services at CHRISTUS St. Michael Health Care System in Texarkana, Texas, which uses a hospital-developed form for following the Universal Protocol and has 11 ORs, where about 25 to 40 cases a day are performed. Giese says the nurse writes the information on the board during room setup, so when the patient arrives and the time-out is performed, the whiteboard is a visual reminder that can be seen by everyone on the surgical team. Soon, use of the board will be mandatory in the organization.
How do briefings work?
The vast majority (97%) of nurses report that the surgeon is responsible for marking the operative site. Only 4% use RNs and 1% use another team member. Responsibility appears to shift when it comes to implementing briefings. More than two thirds (67%) of respondents say perioperative nurses take the lead in this area; surgeons provide that leadership in fewer than a quarter (23%) of facilities (see Team members included in the briefings/communication techniques.)
In most cases (78%), all team members participate in the briefing.
Many nurses report problems with implementing the communication techniques, particularly staff and physician resistance. "We still have physicians who aren't onboard," says Giese. Not surprisingly, time is a factor. "They (the surgeons) want the RNs to hurry through the time-out so they can get started even though it takes less than 15 seconds to do a proper time-out," says one nurse. "We have seen no change at all (as the result of implementing time-outs) except an increase in irritation from surgeons, physician assistants, and anesthesia providers." "Surgeons tune out nurses," says another.
Part of the challenge may be perception. According to a recent quality improvement project conducted by the Veterans Health Administration in 34 hospitals, "Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses."1 The study authors said understanding these differences in perception is an important factor in improving teamwork.
Another potential problem is that surgeons' goals sometimes differ from nurses. Years ago, Tom Portel, RN, CNOR, a nurse with more than 30 years of OR experience, attended his first Association of periOperative Registered Nurses (AORN) Congress and still remembers this comment about the nurse/surgeon relationship: "The surgeon is only concerned with a) getting his patient on the OR schedule, b) getting the operation ‘finished’ in an efficient and timely manner, so that c) he can get to his office." Portel notes, "Believe me, not much has changed."
Giese says education about communication tools needs to start early in physicians' training to help rectify the problem. "When is the checklist idea going to be implemented in medical school?", she asks. "The burden is on the nurses for overseeing the process, but if it was part of physician training, that wouldn't be the case."
Although medical schools are making efforts to increase content on patient safety, including checklists, implementation has been slow. In fact, a March 2010 report from The Lucian Leape Institute at the National Patient Safety Foundation noted that U.S. medical schools aren't doing enough to teach physicians about providing safe patient care.2
Other nurses complain that the various communication techniques have become too onerous and cumbersome. "We've gone a little overboard with three time-outs," reports one nurse. "To a staff nurse, this becomes yet another piece of paper or process that gets in the way."
Others claim the tools are damaging the very thing they're meant to improve—communication. "More work and aggravation for the nurse," says one respondent. "Many angry physicians. Just one more thing to put a wedge between us."
A common complaint was the length of the checklists. "What is included...goes overboard," says one respondent. "We only need the basics. We don't need to talk about all the equipment, implants, etc.; things that have been planned and discussed before this point are included in our time-out. It should be patient's name, surgeon, procedure, site and side if needed, allergies, and antibiotics given—the things that are for the final verification. To go on and on about everything else dilutes the impact of the basic information."
Another nurse agrees saying, "Our institution keeps adding things to the time-out, which makes it long and cumbersome. We feel that this takes away from its effectiveness because it buries the important things like correct side/site/procedure among information that should be dealt with before the patient is asleep (instruments are sterile, implants in the room, etc.)"
Portel worries that lengthy checklists will negatively affect patient care. "Again, time is crucial," he says. "My mentors taught me ‘haste makes waste’ but the big word today is ‘multitask’ and how it relates to the bottom line." As another nurse says, "How can an RN pay attention to the patient and surgeon during short procedures when her paperwork responsibilities keep getting more demanding?"
Revisions mean communication techniques are always a work in progress. While the intent, of course, is to improve, constant change can have detrimental effects. One nurse says, "Several members of the OR team no longer take this step seriously due to the micro-management and constant tweaking of the time-out."
A standard communication tool can lull staff and physicians into complacency, say some nurses. One respondent says, "I believe there's some danger in these techniques becoming somewhat rote...I also believe that sometimes staff and physicians become complacent and merely go through the motions (without paying attention)."
Another nurse agrees that the team does it by rote. This was demonstrated recently when the entire team agreed they had everything they needed for the procedure and in fact they had everything but the right procedure!"
Ultimately, constant revisions and increasing length of processes can lead to what Goeschel calls "checklists and communication fatigue."
Do they work?
Do communication techniques reduce errors? Many nurses say yes. "You get good cooperation among team members," says Dolores Zihal, RN, CNOR, a staff nurse in a five-OR VA hospital in North Port, N.Y., which uses the WHO checklist. "It makes you more aware of providing better care. You're more attuned to the patient. If you go step-by-step on the checklist, you won't forget anything."
For example, one respondent says a checklist helped identify the wrong patient in the room, and several others note that better communication has helped them to adhere to the Surgical Care Improvement Project requirement to deliver prophylactic antibiotics within 1 hour of surgery. "I've seen more awareness of patient factors that could impact care such as wrong paperwork, wrong site specified, wrong equipment," adds one nurse.
Many respondents say communication techniques benefit patients and improve teamwork. For example, one nurse says despite no decrease in the error rate, there has been "an increase in ‘interest’ in the patient care process, teamwork, and intra-op communication re: the patient's care, planning, and interventions."
Figure. Team members...Image Tools
However, most nurses answered the open-ended question about whether communication techniques have decreased errors by saying there had been no change. (Note: The question didn't specify the type of errors.)
When it comes to the big error—wrong-site surgeries—it isn't clear whether standardized communication techniques are making a difference. "People say they're doing the right thing, using the Universal Protocol, doing the time-out, but nationally, reports of wrong-site surgeries haven't gone down at all," says Goeschel.
This might reflect that teams are doing a better job of reporting errors, or that teams haven't yet found the best way to implement these techniques in their local settings.
Despite concerns about time, checklists might be effective in reducing costs, according to a study in Health Affairs. A decision analysis comparing implementation of the WHO surgical checklist to existing practices in the U.S. found that if a hospital has a baseline major complication rate after surgery of at least 3%, the checklist would generate cost savings once it prevented at least five major complications. The study authors concluded that "using a checklist would both save money and improve the quality of care in hospitals throughout the United States."3
Putting the tools to work
Goeschel says it's important to adapt communication techniques to fit your organization's culture. After all, Universal Protocol is the only communication technique that ORs have to follow (as mandated by The Joint Commission), and the protocol contains guidelines, not a prescription, for how to enact the process.
"Not every OR may need to use SBAR, not every site may do briefings the same way. There has to be meaningful thought behind what you use," Goeschel says. She recommends local testing and adapting of tools and adds, "Being sure to include front-line caregivers (nurses, physicians, support staff) in modifying tools is pivotal to success."
Mona Eldroubi, BSN, RN, CNOR, IV, perioperative setting, MHHS/Katy Hospital, Katy, Texas, agrees. "I think bedside nurses aren't being given the chance to participate in decision making for such important issues, and whoever is developing these procedures has been away from the bedside for a long time. They're complicating the nurse's job instead of helping and supporting them," she says, but adds that the tools improve communication between the physician and the nursing team.
When creating tools, it's helpful to review evidence in the literature. For example, according to a study by Berenholtz et al. reported in The Joint Commission Journal on Quality and Patient Safety, the main "tension" is whether communication tools should include structured data (for example, a checklist) or open-ended questions (for example, asking how the next patient will be harmed).4 The authors conclude that a combination of both is likely important. Checklists ensure patients receive evidence-based interventions, while open-ended questions provide an opportunity for team members to speak up if there are concerns.
Goeschel adds that each OR needs to understand its own safety risks and to share safety problems with staff and surgeons. "Communication is a two-way street," she says. OR leaders might share, for example, near misses and the scope of problems such as not giving antibiotics before surgery.
When implementing a communication tool, she advises, "Start small and give feedback."
That includes having a plan to close the loop with communication techniques. "You have to demonstrate that using the tools and processes make care safer and improve outcomes, otherwise people will stop using them," she says. The Berenholtz study is a useful reference and provides detailed recommendations for implementing communication tools.4 Interestingly, the authors found that it took an average of 2.9 minutes to complete the briefing tool, a small investment to promote patient safety.
Persistence pays off. "When it first came out, people were making fun of it," says Zihal. "We persisted and now it's routine and a lot of the surgeons initiate it."
"We have slowly seen a general decrease in surgeon resistance to participate in time-outs," says one respondent. "We've been adamant about the need to do them and have even gone so far in some cases as to refuse to hand the surgeon the skin scalpel until he or she has completed their time-out (if dealing with a habitual offender)."
Goeschel says that continued education is key to smooth implementation of processes. She regularly checks the National Patient Safety Foundation forum (http://www.npsf.org) to read the latest on patient safety topics. "One of the things that stuns me is the long strings of conversations from people who are searching for basic information. You begin to appreciate how large the gap is in knowledge base and skill set."
Giese advocates educating patients, who are already becoming increasingly involved in their care. "The (Joint Commission) Speak Up campaign is great, but they need to put it on TV," she says. Patients can become allies; Giese says staff members have the patient give his or her surgeon the pen used to mark the surgical site. "They (surgeons) are less likely to tell the patient ‘no’", she notes.
Focus on the patient
Some patient safety experts, such as Peter Pronovost, MD, PhD, at Johns Hopkins School of Medicine, caution that checklists are not a "magic wand" for preventing errors. Instead, a culture that supports communication from the entire team is the key.
The bottom line is that it takes people to keep the patient safe. "I would call these techniques helpful," says one nurse, "but the quality and commitment of the persons involved is what ultimately determines the excellence of the outcome. No tool is effective if people aren't 100% committed to giving their best."
Adds Goeschel, "We can't lose sight of why we are doing (the process) and its effect on outcomes."
About the communication techniques
Preoperative briefing: A communication tool to facilitate interdisciplinary communication. Typically done after final positioning of the patient and before the incision. May include closed questions, open questions, or a combination of the two. In a study, 90% of participants agreed with the statement, "Briefing is an effective strategy to improve interdisciplinary communication," and 90% said that the briefing was "an effective strategy to improve teamwork."2
SBAR: SBAR provides a standard format for communication among team members. It's particularly useful for patient "handoffs," such as from the OR to the postanesthesia care unit (PACU). Michael Leonard, MD; Suzanne Graham, PhD, RN; and Doug Bonacum adapted SBAR, originally used by the military, to the healthcare setting. In the OR, SBAR is used for shift changes, handoffs between OR and PACU staff, and to communicate with the surgeon about a patient.
Universal Protocol (for Preventing Wrong- Site, Wrong-Procedure, and Wrong-Person Surgery): First required by The Joint Commission in 2004, the current protocol contains three sections: conduct a preprocedure verification process, mark the procedure site, and perform a time-out. It's not a checklist, but rather a guide for what should be done at each step. Access a poster of the 2010 protocol at http://www.jointcommission.org/NR/rdonlyres/F8046F2C-A8A2-412F-88D4-E1762BCC5C26/0/UP_Poster.pdf
The protocol was revised due to concerns about the specificity of the 2009 protocol and its practical implementation.
WHO Surgical Safety Checklist: Launched in 2008 as part of the Safe Surgery Saves Lives initiative, use of the checklist increased the rate of adherence to standards of surgical care from 36% to 68%. It was tested in eight hospitals around the world, including Seattle, London, and Tanzania. The checklist is divided into three sections: before induction of anesthesia, before skin incision, and before the patient leaves the OR. WHO states, "Additions and modifications to fit local practice are encouraged." You can download the 2009 version (available in other languages, including Spanish) at http://www.who.int/patientsafety/safesurgery/en/.
In March 2010, the AORN introduced the Comprehensive Surgical Checklist, which uses color keys to represent the respective practices and recommendations of the WHO, The Joint Commission, and areas where they overlap. "Our members were concerned by the need to reference multiple checklists when they were in the middle of a procedure," said AORN executive director/CEO Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN. "A single checklist that incorporates all the key steps simplifies the process and should reduce the risk of surgical errors." Download a free copy at http://www.aorn.org/PracticeResources/ToolKits/CorrectSiteSurgeryToolKit/Comprehensivechecklist/.
About the respondents
* Most (87%) of the 578 respondents work in a hospital OR, and 14% in ambulatory care, either in a hospital or at a freestanding surgicenter.
* Of those who work in a hospital, nearly half (44%) usually work in general surgery, followed by orthopedics (22%), management (14%), and laparoscopy (12%).
* Nearly half (47%) are staff nurses; 27% identified themselves as managers or administrators and 15% as staff development educators.
* Nearly half (48%) of those who responded to the survey have 21 or more years of perioperative nursing experience; nearly three-quarters (74%) had more than 10 years of experience.
© 2010 Lippincott Williams & Wilkins, Inc.