Effective interprofessional team communication is widely recognized as a central factor in the delivery of safe, high-quality health care.1,2 While a few, select clinical domains have developed educational programs that explicitly target team communication,3 in many health professional contexts, this skill is taught in an ad hoc fashion. Such an implicit curriculum of trial and error not only makes it difficult to monitor and shape novice learning, but also can result in unintended attitude acquisition by novices in team settings.4 As accreditation standards are making increasingly clear, a coherent, evidence-based curriculum is necessary to ensure trainee competence in interprofessional communication.5,6
The evidence base necessary to fulfill this mandate has been evolving in recent years. Naturalistic investigations of team communication have revealed it to be a complicated social phenomenon regularly punctuated with tension-filled events that are provoked by recurrent catalysts.7–9 For example, observations of operating room (OR) teams in diverse institutional contexts suggest that regular patterns of OR team tension arise.10 Tension is neither inherently good nor bad: it can help the individual to productively focus on a problem or it can undermine group collaboration. We have been particularly interested in tense communicative events that have a “ripple effect,” extending a negative influence across time (i.e., resurfacing to disturb the subsequent case), space (i.e., spreading tension to the next OR theatre), and participants (i.e., extending to include individuals not involved in the originating event). Our research has suggested that such tension can accumulate during the case or the day, building toward open conflict and contributing to poor collaborative relations among team members.7,10 Further, our research has found not only that team members interpret such moments of tension and related communicative events differently, but also that professional perspective strongly influences these interpretations.11
The next step towards a curriculum in OR team communication is the replication of these naturalistic research findings in a controlled and standardized environment. Such replication would help to establish the reproducibility and generalizability of the naturalistic findings. This, in turn, would help to guide and support the development of curricula that will have relevance for operating room trainees in a range of professions and institutional contexts. In an era where educational resources are scarce and multi-institutional educational interventions scarcer, a portable curriculum based on generalizable evidence is necessary to facilitate broad uptake and sound assessment.
This study, therefore, sought to replicate prior, naturalistic findings regarding team members' perceptions of team tension using quantitative measures in a controlled and easily reproduced environment with a larger and more diverse sample of participants. To this end, we created a set of standardized but realistic tension-filled video vignettes, and quantitatively compared nurses', surgeons', and anesthesiologists' perceptions of team tension in these standardized vignettes using structured rating scales.
Method
All phases of the study received Research Ethics Board approval at all relevant institutions. Participation in all phases was voluntary.
Development of the vignettes
Three 3-minute videos representing realistic, multifaceted OR tension scenarios were constructed based on prior research6,7,9 and interviews with OR team members. From this consultation process, four draft scenarios were fully constructed in written format and distributed to 39 OR team members for their input about which three were most relevant and important, and should be produced as a video scenario for research and educational purposes. The top three scenarios were selected and produced using professional actors. Each scenario was divided into three natural segments to establish multiple observation points in a set of increasingly tense situations.
Scenario 1: (a) The circulating nurse has called for assistance refilling the hydro-jet dissector. While the team waits, the surgeon declares that “everyone in the OR” should learn to operate new equipment (video segment 1). (b) The nurse coordinator enters the OR and announces that the last case of the day will be cancelled because the current case is running late. The surgeon argues with her in front of the team (video segment 2). (c) Upon the nurse coordinator's exit, the surgeon entreats the nurses and anesthesiologist to stay late for the last case. The anesthesiologist refuses (video segment 3).
Scenario 2: (a) During an emergency case at night, the surgeon is frustrated by his inability to get the instrument he prefers (video segment 4). (b) The frustration erupts in an open, undirected comment about the fact that these problems never arise during the day. At the same time, the anesthesiologist asks repeatedly, and with increasing urgency, for assistance in sending a blood gas (video segment 5). (c) Later, the resident's insistence upon a subcuticular closure provokes conflict with nursing and with anesthesia (video segment 6).
Scenario 3: (a) During a Whipple procedure, the surgeon questions tersely why the patient's arm needs to be extended on an armboard. The anesthesiologist notes that the arterial line is positional and then, turning away from the surgeon, explains this to a medical student (video segment 7). (b) A student nurse is scrubbed on this complicated case. The surgeon repeatedly corrects her instrument handling and she becomes increasingly nervous (video segment 8). (c) The surgeon's glove is nicked when the student nurse is handing a pair of scissors. The surgeon yells at the nurse to drop the instrument. Blood loss in the case is significant; the surgeon and anesthesiologist debate responsibility for low blood pressure (video segment 9).
Rating scales
Following each video segment, participants were asked to rate each of the three professions (surgery, nursing and anesthesia) on three dimensions: (1) the level of tension likely being experienced by the representatives of that profession; (2) the extent to which members of that profession were responsible for creating the tension; and (3) the extent to which members of that profession were responsible for trying to resolve the tension. The nine ratings per segment (three questions for each of three professions) were completed using seven-point numbered rating scales that were anchored at the value 1 with the phrase “not at all” and were anchored at the value 7 with the term “extremely.”
Data collection
The videos were formatted using Windows Media Format for presentation in a computer environment. The rating scales were formatted to be completed on a computer using radio buttons. The video segments and rating scales were compiled into a self-contained program that presented the three segments for each scenario in chronological order and presented the three scenarios in a constant order for all participants. The program was designed to present the nine questions for completion following each segment and was structured such that users could not move to the next video segment without completing the surveys on the segment just viewed. (See Figure 1 for a screen shot of the tool ready for completion of the ratings.) The program could be used on any computer that had an Internet connection (low or high speed). The Internet connection was necessary because the survey data completed by users were sent to a secure server at the study institution for later retrieval and analysis.
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Figure 1:
Operating Room Tension Survey completed by participants for each of nine video segments (three segments for each of three scenarios).
Participants
A total of 72 OR team members from Canadian and U.S. institutions participated. These included 30 surgery participants (18 staff, 12 trainees), 20 nursing participants (20 staff, 0 trainees), and 22 anesthesia participants (13 staff, 9 trainees). Staff participants represented a range of experience in the OR. Eight staff participants (2 surgeons, 1 anesthesiologist, 5 nurses) had 0–4 years of experience; 12 (5 surgeons, 4 anesthesiologists, 3 nurses) had 5–10 years of experience; 16 (8 surgeons, 4 anesthesiologists, 4 nurses) had 11–20 years of experience, and 15 (3 surgeons, 4 anesthesiologists, 8 nurses) had over 20 years of experience working in the OR.
Procedure
Data were collected over the course of eight half-day and full-day sessions scheduled between May and November of 2003. Participants were recruited at public arenas (e.g., specialty specific conferences, staff lounges) with a research assistant (RA) inviting participation and the participant completing the survey with the RA available for support and questions. This recruitment process was often facilitated by members of the OR community (e.g., a designated anesthesiologist), who helped to raise their colleagues' awareness about the date and time that the RA would be present. Each participant completed the study independently. Upon completion of all rating forms for all video segments, each participant was informally asked to comment verbally on the authenticity of the scenarios. These comments were summarized in handwritten notes.
Data analysis
Data from each of the three questions (level of tension, responsibility for creating the tension, and responsibility for resolving the tension) were independently analyzed using a three-way, mixed-design analysis of variance, with video segment (nine segments) and profession of the actor (surgery, nursing, anesthesia) as repeated-measure factors, and profession of the rater (surgery, nursing, anesthesia) as a between-subjects factor. For the purposes of our study, the critical terms in the analyses were the interaction terms involving the profession of the rater and the profession of the actors. Significant interactions at this level would suggest to us that the different professions were viewing each others' experience of and responsibility for tension differently, thereby replicating earlier qualitative findings in this more controlled and contrived context.
Preliminary analyses revealed no effect of participants' status as staff versus trainee in the pattern of responses, so all analyses are presented with data from staff and trainees combined in order to maximize power in the design.
Results
Responses from the informal postsurvey interviews suggest that the participants found the scenarios to be a believable and authentic representation of common, tense OR team communication exchanges; however, a few surgeon participants felt the representation of surgery was stereotyped and perhaps overly negative.
Analysis for perceived level of tension revealed a main effect of segment (some moments were generally more tense than others, F = 35.46, p < .001), a main effect of the profession being rated (across all segments some professions were generally more tense than others, F = 169.36, p < .001), and an interaction of segment by profession portrayed (segments were differentially tense for the various professions being portrayed, F = 44.19, p < .001). However, importantly, there was no significant interaction of the rater's profession with segment (all professions rated the overall tension of the various segments in the same way, F = 1.19, ns), with the profession being portrayed (all professions rated the relative tension of the portrayed professions in the same way, F = 0.77, ns) or in the three way interaction (the professions agreed about who was tense when, F = 1.23, ns). Graphically, these results are displayed in the first column of graphs in Figure 2. As can be seen in the first column, the ratings from the surgeons (top panel), nurses (middle panel), and anesthesiologists (bottom panel) are virtually indistinguishable with regard to the relative levels of stress for each of the three professional groups.
Figure 2:
Surgeon, nurse, and anesthesiologist ratings of each profession's level tension, responsibility for creating the tension, and responsibility for resolving the tension for each of the nine video segments (three segments for each of three scenarios).
By contrast, in ratings of who was responsible for creating the tension in each scenario, there was a significant interaction of portrayed profession by rater profession (the profession of the rater affected perceptions of the overall level of responsibility of each profession for creating tension in these scenarios, F = 2.86, p < .05). Further, there was a significant three-way interaction among segment, profession portrayed, and rater profession (the profession of the rater affected perceptions of how the responsibility for tension shifts across professions from one segment to the next, F = 2.26, p < .01). Graphically, these interactions between profession of the rater and profession of the actor are apparent in the second column of graphs in Figure 2. Looking at the data from video segment 2, for example, the surgeon raters (top panel) rated the surgeons and nurses as being equally responsible for creating the tension and rated the anesthesiologists somewhat lower. By contrast, the nurses (middle panel) rated the surgeons as highly responsible, but identified the nurses as being less responsible (equal to the responsibility level of the anesthesiologists). The anesthesiologist raters (bottom panel) showed an even larger gap in responsibility for the tension between surgeons and nurses, but rated the anesthesiologists as having virtually no responsibility for the tension created.
Similarly, in ratings of who was responsible for resolving the tension, there was a significant three-way interaction (the profession of the rater affected perceptions of how responsibility for resolution shifts across the professions from one segment to the next, F = 1.91, p < .01). In fact, the graphical representation of the ratings of responsibility for resolving the tension (the panels in column three of Figure 2) is remarkably similar to the pattern of who is responsible for creating the tension (the panels in column 2), suggesting that there is a strong relationship between the raters' sense of who is responsible for creating tension and who is responsible for resolving that tension.
Discussion
These quantitative data generated under artificial, standardized conditions in which participants rated simulated vignettes viewed on videotapes provided confirmation and generalizability of earlier, naturalistic qualitative work exploring patterns in team members' interpretations of communicative tension on the OR team. Team members were largely in agreement when interpreting each other's tension levels. Each group seemed to know how tense the other groups would feel in each situation. However, consistent with previous work, team members who were rating the videos frequently differed by profession in their perceptions of the various professions' level of responsibility for creating and resolving the tension. Often team members rated their own profession as having relatively less responsibility for creating the tension compared to the ratings by and for the other professional groups. Furthermore, the pattern of data seen in the ratings of responsibility for creating the tension was closely mirrored in the pattern of data seen in the ratings of responsibility for resolving the tension. It appears that raters generally followed an “if you broke it, you fix it” approach to tension resolution, which highlights even more strongly the problem of differing perceptions regarding who is the cause of the tension. Clearly, interprofessional educational efforts should be focused on addressing the disparity of perspectives and their implications for team function and patient safety.
The success of the video rating system in uncovering these discrepancies also provides the opportunity for innovative educational development in this important domain. The carefully constructed videos present a unique tool for use in teamwork instruction, and the research evidence provides a foundation on which to build curricula regarding team tension and its resolution. In fact, we have taken the first step down this path. To explore the educational application of our research materials and results, we have developed a multidisciplinary seminar on team tension that incorporated the video survey activity, small-group discussions, and didactic presentation of survey results. The educational seminar was envisioned as an opportunity for novice OR team members from surgery, anesthesia, and nursing to learn and reflect together on the causes and consequences of communicative tension in the operating room. The seminar was delivered to a group of novice OR team members in two settings, one in Canada and one in the United States. It engaged participants in critical analysis of behaviors in the videos, and encouraged them to share, across professional boundaries, their own experiences of team tension as novice team members. Although further work is required to evolve, refine, and evaluate this approach, preliminary feedback from seminar participants suggests that it is certainly viable as an approach to training novices for competence in this important skill in an interprofessional context.
As educators, we recognize that novices require explicit, evidence-based instruction to acquire technical skills and clinical knowledge in the health professions. Similarly, novices require such instruction to acquire team communication skills, particularly the sophisticated strategies needed to ensure productive interprofessional collaboration in situations of tension. This instruction is necessary not only to ensure competent future health care professionals, but also to cultivate a positive learning environment for current trainees. Our video rating results and preliminary educational development work provide a starting point for incorporating such communications training into a postgraduate curriculum in an evidence-based and pedagogically sound manner using generic and portable materials. Building on this work, future efforts should combine a multi-institutional intervention with an evaluation approach that measures whether participation in a series of such seminars impacts team communication behavior in the OR.
This research was supported by the Association for Surgical Education (ASE) Foundation's Center for Excellence in Surgical Education, Research, and Training (CESERT). Dr. Lingard is supported by a Canadian Institutes of Health Research New Investigator Salary Award and as the Bank of Montreal Professor in Health Professions Education Research. Dr. Regehr is supported as the Richard and Elizabeth Currie Chair in Health Professions Education Research.
References
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Section Description
Moderator: Michael Mintzer, MD
Discussant: Jim Gordon, MD
