Introduction: Organizational behavior and management fields have long realized the importance of teamwork and team-building skills, but only recently has health care training focused on these critical elements. Communication styles and strategies are a common focus of team training but have not yet been consistently applied to medicine. We sought to determine whether such communication strategies, specifically “advocacy” and “inquiry,” were used de novo by medical professionals in a simulation-based teamwork and crisis resource management course. Explicit expression of a jointly managed clinical plan between providers, a strategy shown to improve patient safety, was also evaluated.
Methods: Forty-four of 54 videotaped performances of an ongoing team-building skills course were viewed and analyzed for presence of advocacy and/or inquiry that related to information or a plan; inclusion criteria were participation of a nonconfederate obstetrician and an anesthesiologist. Verbal statement of a jointly managed clinical plan was also recorded.
Results: Anesthesiologists advocated information in 100% of cases and advocated their plans in 93% of cases but inquired information in 30% of cases and inquired about the obstetricians’ plans in 11% of cases. Obstetricians advocated information in 73% of cases, advocated their plans in 73% of cases, inquired information in 75% of cases, and inquired about the anesthesiologists’ plans in 59% of cases. An explicitly stated joint team plan was formed in 45% of cases.
Conclusions: Anesthesiologists advocated more frequently than obstetricians, while obstetricians inquired and advocated in more balanced proportions. However, fewer than half of the teams explicitly agreed on a joint plan. Increasing awareness of communication styles, and possibly incorporating these skills into medical training, may help teams arrive more efficiently at jointly managed clinical plans in crisis situations.
From the Department of Anesthesia, Critical Care, and Pain Medicine (R.D.M., M.C.M.P.-S., J.W.R., R.S., D.B.R.), Massachusetts General Hospital; Department of Obstetrics Gynecology and Reproductive Biology (T.B.W., R.G.), Brigham and Women’s Hospital, Boston; and Center for Medical Simulation (R.D.M., M.C.M.P.-S., T.B.W., R.G., J.W.R., D.B.R.), Cambridge, MA.
Reprints: Rebecca D. Minehart, MD, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (e-mail: firstname.lastname@example.org).
Three of the authors (R.D.M., D.B.R., M.C.M.P.-S.) were recipients of grants (from the Foundation for Anesthesia Education and Research, the Anesthesia Patient Safety Foundation, and the National Patient Safety Foundation) for other projects during the time that this article was in preparation. Two of the authors (R.S., J.W.R.) received honoraria for presenting educational sessions at academic conferences.
This study was made possible by departmentally supported nonclinical (research) time.
None of the authors received outside funds for any part of this study.
Recent advances in improving patient care perioperatively by using checklists1 highlight the need for explicit communication among team members to improve safety. Training in communication strategies have long been used in aviation, the military, organizational behavior, and management fields to enhance strategic and tactical decision making and facilitate teamwork and planning.2–5 Communicating effectively under time pressure and high stakes in a way that supports safety and reliability requires a shift from the usual social norms of politeness. Politeness norms put a premium on not constraining others’ actions and being indirect about criticism.6,7 In contrast, organizing for high reliability through conversation requires professionals to reveal quickly such things as their situation assessments, perspectives, working diagnoses, clinical concerns, or critiques of others’ actions all while inviting, or at least not restricting, input from others.2,8–12 Sharing one’s point of view and eliciting others’ quickly and efficiently help with error detection and recovery and can reduce or prevent fixations.13,14
Research from a variety of areas including effective feedback,15 the function of different “speech acts,”16,17 provider-patient “conversation analysis,”18 and in-depth qualitative analysis of organizational interventions19,20 yields the insight that there are a limited number of fundamental building blocks of speech. Types of speech can be combined in support of technically focused, efficient conversation2 or to obfuscate, misdirect, or smooth over.19,20 Speaking has been labeled the most significant form of human action and can be classified into 4 different parts: framing, advocating, illustrating, and inquiring.21 More recently, the quality of communication (measured by evaluating patterns of advocacy and inquiry) has been applied subsequently to medical debriefing with the explicit goal of providing feedback after simulation-based courses.22 Advocacy is typically defined as a statement, observation, or opinion; inquiry is an attempt to elicit information from another in the form of a question.22 Such communication patterns or strategies, while accepted in the business world, are still early in their formal measurement, integration, and application in the health care field. Pairing advocacy and inquiry can lead to improved communication, particularly through cycles of self-correcting dialogue in which people publicly articulate their beliefs, conclusions, or emerging views and test them by inviting input.19,20,23–26 Describing one’s thinking and monitoring or inquiring into the emergent views of others through “heedful interrelating” or “cross-monitoring” are associated with organizations that successfully organize for high-reliability and robust teamwork.27–29 Articulating one’s thinking out loud (advocacy) and inquiring into others’ “sense making” about a situation contributes to cocreation of plans among health care team members.12,30 Conversely, when team members use 1 type of communication exclusively, this may lead to dysfunctional communication patterns and escalating error as pressures to be polite obfuscate what each party is thinking and prevent disconfirmation of emergent theories or plans.6,7
The conversational dynamics produced by using only 1 type of speech predominantly can undermine error detection and correction, as well as trust. Using inquiry alone or advocacy alone produces these familiar dysfunctional patterns: soft questions designed to hint at a solution,31 interrogation-like questioning that is experienced as an attack,32 gentle-sounding leading questions strung together in a pattern called easing in that are experienced as manipulation,20 or a landslide of assertions designed to convince via data overload, the strong unilateral assertion of a point of view designed to convince by its force.33,34
In the perioperative environment, failure to share and elicit different points of view reduces learning in the moment,5 potentially leading to inadequate information for planning patient care. One area in the medical field that has been inconsistently evaluated is communication between health care providers, specifically the quality of information that is passed between team members caring for a patient in an emergency situation. There is evidence that, when providers explicitly state their emerging concerns, situation assessments, or differential diagnoses, this improves patient safety in crises by expediting the formation of a jointly managed clinical plan.35,36 A jointly managed clinical plan, in this context, refers to joint decision making between providers; theoretically, a “jointly managed clinical plan” could be explicitly stated by 1 team member or more, as long as it accounts for all team members’ clinical considerations. In light of this important evidence, we sought to analyze the verbal communication strategies used, as well as the frequency of jointly managed clinical plans stated aloud, by teams of obstetricians and anesthesiologists involved in a simulated maternal-fetal crisis while participating in a Labor and Delivery (L&D) Crisis Resource Management Course.
Description of naturalistic preoperative communication is still relatively rare. This study builds on a nascent literature that examines speech patterns in the operating room (OR) environment as a way to describe or explain clinical decision making or teamwork.13,37 After institutional review board approval, we analyzed video recordings collected from a recurring L&D Crisis Resource Management Course (Center for Medical Simulation, Cambridge, MA) held between 2004 and 2007. Participants gave written consent for their video to be used for research purposes before participation in the course. We characterized the types of language used by these caregiver teams according to whether they asked questions (“inquiry”) or made statements (“advocacy”) about general information (“info”) or regarding their plan of action (“plan”). We also evaluated whether the teams verbalized a jointly managed clinical plan (“joint plan”) during the course of the crisis situation.
An anesthesiologist and 1 obstetrician or more were called to help perform a cesarean delivery in an otherwise healthy laboring “patient” (mannequin) who had broken her femur in a fall when she tried to ambulate after receiving epidural analgesia. In view of her complex orthopedic fractures, the orthopedic surgeon (confederate) recommended traction stabilization and suggested that a vaginal delivery would be contraindicated. The subject participants were summoned to the simulated OR where a confederate anesthesiologist handed over the case to the incoming subject anesthesiologist, while also administering a dose of local anesthetic through the epidural catheter. Initially, the patient was stable but then became hypotensive and unresponsive because of an unrecognized accidental spinal administration of anesthetic, with resultant total spinal anesthesia. When the participant anesthesiologist attempted intubation, a difficult airway was encountered, forcing a decision point. Concomitantly, the simulated electronic fetal heart rate pattern deteriorated to a deep and prolonged bradycardia, forcing the obstetricians toward a decision point as well. The mother experienced a hypoxic cardiopulmonary arrest. However, the baby was always delivered alive, and the mother ultimately responded to cardiopulmonary resuscitation efforts and recovered.
Of the 54 videos that were initially viewed, 44 were found to be suitable for evaluation. Inclusion criteria were the presence of an anesthesiologist and an obstetrician, both of whom were not employed by the Center for Medical Simulation. In addition, the video had to be of sufficient audio quality for transcription. Demographic information was not collected on participants, but all participants involved were graduates of a residency program and were employed in academic or private practice settings. Many of the area providers had been exposed to simulation before this L&D course through medical school and residency training, but these experiences were not documented for this study. All participants received a standard introduction to simulation, including a written guide on functions of the simulation equipment and expectations of their roles, as well as any special simulation equipment or techniques that would be used. Anesthesiologist “crews” consisted of either 1 or 2 anesthesiologists; the same was true for the obstetrician crews. Overall, each anesthesiologist or obstetrician crew was assessed as a whole and scored based on language patterns that were verbalized by any or all crew members. Both “newly formed” teams (ie, teams with individuals who did not regularly function or work together) and “intact” teams (ie, teams who regularly functioned together) were represented in the courses but were not documented for this study. Videos were then transcribed and analyzed for language patterns using criteria for advocacy and inquiry, further characterizing whether participants were applying advocacy and/or inquiry to information or a plan. Requirements for a statement to be coded included (1) clear conveyance of a message such that an outside observer would infer its meaning (could not be vague); (2) the speaker’s intended recipient was another participant on the complementary team (eg, an obstetrician to an anesthesiologist or vice versa), which was assessed by body language and/or the use of name or title; (3) whether the statement made reference to the ongoing crisis when taken out of context; and (4) whether the statement contributed to the teams’ overall shared understanding of the situation. Statements, such as “Tell me when you’re ready” and “I’m giving ephedrine,” lacked contextual reference, the speakers’ assessments or concerns, or a differential diagnosis and therefore were not coded (see Table 1 for examples of language patterns). “Plan inquiry” statements included the type of plan and the timing or order of plan initiation (eg, an anesthesiologist stating, “Actually, could you hold on a minute?” in response to the obstetrician stating, “Great, so we’re going to do the section right now, then”). Because the participants were immersed in a case while communicating with each other, context could not necessarily be overlooked. We attempted to account for context in that a statement such as “I’m just going to bag her” (referring to bag-mask ventilation, unusual in the context of a cesarean delivery under epidural anesthesia) or a very loudly expressed statement (without explicitly stated recipients) was included in coding. We also coded for an explicitly stated joint plan between the anesthesiologist and obstetrician participants that accounted for joint clinical management of the patient, such that all participants and confederates probably had a unified understanding of the sequence of treatment measures to be initiated. Explicitly stated joint plans were either unilateral (originating from 1 team member but encompassing both anesthesiologist and obstetrician plans) or could be formed through a short exchange between the 2 teams; we did not differentiate between these 2 methods, but joint plans must have been verbally agreed on by both anesthesiologists and obstetricians. Requirements for coding a joint plan consisted of hearing explicit statements for both an obstetric and an anesthetic management plan within a short time interval (<60 seconds) because both obstetricians and anesthesiologists were managing interrelated components of the maternal-fetal crisis. Analysis of video recordings (viewed simultaneously while reading the corresponding transcripts for clarity of language) was performed independently by 2 physician investigators (either 1 anesthesiologist and 1 obstetrician or 2 anesthesiologists), and there was a high degree of consistency in the ratings. There were only 11 (2.8%) discrepancies in ratings of 396 data points, and these were resolved by consensus after a joint review of the discrepant portion of the case by the raters.
Data were formatted in a Microsoft Excel spreadsheet, and frequencies of communication strategies were analyzed. Correlation or association between providers’ communication strategies and explicit statement of a jointly managed clinical plan was analyzed with Kendall τ rank correlation nonparametric test (Free Statistics and Forecasting Software v1.1.23-r7, http://www.wessa.net/rwasp_kendall.wasp#output).
Anesthesiologists advocated information in 44 (100%) of 44 cases, advocated a plan in 41 (93%) of 44 cases, inquired about information in 13 (30%) of 44 cases, and inquired about the obstetricians’ plans in 5 (11%) of 44 cases. Obstetricians advocated information in 32 (73%) of 44 cases, advocated a plan in 32 (73%) of 44 cases, inquired about information in 33 (75%) of 44 cases, and inquired about the anesthesiologists’ plans in 26 (59%) of 44 cases. Explicit joint plans were found in 20 (45%) of 44 cases. There was no statistically significant association between any of the coded communication strategies and explicit statement of a jointly managed clinical plan.
“Good communication” is becoming increasingly valued in medicine today, and “poor communication” has been noted to have a detrimental effect in some situations. In an observational study evaluating analysis of communication in the OR during general surgery and vascular surgery cases, communication “failures” occurred in 30.6% of all communication events.37 An article evaluating obstetric anesthesia liability trends in closed claims noted that poor communication between the anesthesiologist and the obstetrician was cited as a major contributing factor in a third of cases where delaying cesarean delivery led to anesthesia-related newborn death or brain damage claims.38 “Improved communication” was the most common recommendation to improve patient safety given by more than 1000 health care workers in a survey study.39 Recently, a systematic review of published literature evaluating interprofessional communication in the setting of surgical and anesthetic care called for more standardized communications, as well as further exploration of current practices of information transfer and communication.40 What remains elusive, however, is what exactly constitutes good communication, especially when managing a clinical emergency. By raising awareness of common communication strategies used by organizational behavior and management fields, it is possible that we may uncover patterns of speaking that may lead to more cohesive patient care, especially when time pressures are high, such as in crises.
In the maternal-fetal simulated crisis cases analyzed, anesthesiologists used advocacy for both information and plans more often than their obstetrician teammates (Fig. 1). However, obstetricians more frequently inquired than anesthesiologists did. Although anesthesiologists used advocacy more than inquiry, obstetricians tended to advocate and inquire in more balanced proportions. Given that explicitly stating concerns, assessments, or differential diagnoses in the face of crises and inviting input from others may expedite forming a unified approach to patient management, it follows that the use of both advocacy and inquiry may lead to better shared understanding during a crisis.
The ultimate goal in any L&D crisis is the well-being of both the mother and the baby. In the setting of a maternal cardiac arrest, the general guideline is to have the delivery accomplished within 5 minutes of the maternal arrest. This is thought to optimize the chances of both the baby’s intact survival and the mother’s intact survival. This recommendation was introduced in the obstetric literature in 1986, reviewed again in 2005, and although this has not been proven, it is the accepted guideline with regard to timing for a perimortem cesarean delivery.41–43 We observed in our debriefing discussions that most of our participant obstetricians were not aware of this recommendation and thought that proceeding with the delivery of the baby was actually sacrificing the mother. They seemed unaware that the delivery of the baby increased the chance of a successful resuscitation of the mother by increasing the maternal cardiac output and perfusion of vital organs. In contrast to the obstetricians, we found that many of our participant anesthesiologists were aware of this recommendation and its benefits to both the mother and the baby but did not verbalize it during the case. This refrain from “speaking up” was explored during the debriefings but was not documented for the sake of this study, but many factors that are known to inhibit speaking up may have been at play.44
Our hope is that encouraging more advocacy and inquiry across the drapes may lead to better information sharing and more opportunities to formulate the appropriate joint plan. Jointly managed clinical plans were explicitly stated in fewer than half of the cases. This leads one to question if team communication would be improved by encouraging anesthesiologists to become more adept at inquiring, or encouraging obstetricians to advocate and inquire more frequently. However, there were no measured correlations between the type of language used and the explicit statement of a joint plan, which suggests that there may be other factors at play that promote or hinder teams to explicitly state joint plans.
There are a number of issues that may limit the generalizability of this study. First, because this was a retrospective analysis, of course, with videos spanning a 3-year period, there may have been differences in course delivery or debriefings that may have affected participants’ performances during the study case. Substantive differences in “trigger” language from scripted confederates were not noted by the study raters. Thus, such differences from course to course were probably minor. Second, we do not know if participants had received specific communication-related training in the past and how this affected our observed data. Third, the anesthesiologists and obstetricians were being observed by peers when they participated in the study case, and this may have affected their performance. Fourth, because the simulated cases themselves were “standardized” in that they covered all major clinical events but were not strictly controlled for all factors or for simulation-related “noise” (eg, unfamiliarity with equipment causing delays or confusion and rare equipment malfunctions), we do not report clinically relevant outcomes such as time to delivery of the fetus, time to resuscitative measures, and the like. Finally, because this was a simulated crisis, we do not know if the “simulation” itself affected communication behavior. Although the participants generally seemed engaged in the crisis and universally took the exercise seriously, we do not know how accurately our observations reflect behavior in the actual clinical environment with real patient lives at stake.
This study opens new questions worthy of study. We did not compare the communication patterns of newly formed teams versus intact teams in an effort to better understand how we work and communicate in groups. In addition, we did not examine whether participating in educational programs using simulated cases actually improve communication patterns in the simulated environment or, more importantly, translate to improvement in communication in the clinical environment. Certainly, we do not know training doses, learning curves, skill extinction, or other characteristics of skill development and retention.
We have described the pattern of communication between physician specialists during a particular simulated crisis. Improvement in teamwork and subsequent benefit to patient care may result if these types of communication patterns are better understood and can be improved via effective educational processes.
The authors thank all health care providers who participated in the L&D Crisis Resource Management Course 1 held at the Center for Medical Simulation in Cambridge, Massachusetts, and all employees and volunteers at the Center; without them, this work would not be possible.
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