Secondary Logo

Journal Logo

Action Research, Simulation, Team Communication, and Bringing the Tacit Into Voice Society for Simulation in Healthcare

Forsythe, Lydia PhD, MA, MSN, RN, CNOR

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: October 2009 - Volume 4 - Issue 3 - p 143-148
doi: 10.1097/SIH.0b013e3181986814
Empirical Investigations
Free

Background: In healthcare, professionals usually function in a time-constrained paradigm because of the nature of care delivery functions and the acute patient populations usually in need of emergent and urgent care. This leaves little, if no time for team reflection, or team processing as a collaborative action. Simulation can be used to create a safe space as a structure for recognition and innovation to continue to develop a culture of safety for healthcare delivery and patient care.

Methods: To create and develop a safe space, three qualitative modified action research institutional review board-approved studies were developed using simulation to explore team communication as an unfolding in the acute care environment of the operating room. An action heuristic was used for data collection by capturing the participants’ narratives in the form of collaborative recall and reflection to standardize task, process, and language.

Results: During the qualitative simulations, the team participants identified and changed multiple tasks, process, and language items. The simulations contributed to positive changes for task and efficiencies, team interactions, and overall functionality of the team.

Conclusion: The studies demonstrated that simulation can be used in healthcare to define safe spaces to practice, reflect, and develop collaborative relationships, which contribute to the realization of a culture of safety.

From the Department of Perioperative Services, Oklahoma University Medical Center, Oklahoma City, Oklahoma.

The author declares no conflict of interest.

Reprints: Lydia Forsythe, PhD, MA, MSN, RN, CNOR (e-mail: lydia.forsythe@hcahealthcare.com).

In healthcare, professionals are constrained by the communication boundaries of the medical hierarchy. This boundary includes team roles and the behaviors that follow suit. As a result of the hierarchy and within the context of communication, it is difficult to change behavioral patterns related to role submission and dominance.

Back to Top | Article Outline

HEALTHCARE COMMUNICATION, ISSUES, AND DEVELOPING A SAFE SPACE

Depending on one’s rank or position in the hierarchy, individuals know there is a practical way to communicate not to disturb the hierarchical relationship. Within an implicative sense people also understand that if specific things are said in certain ways within conversations, specific responses are elicited. Obviously, the responses can be good or bad. Given the boundaries of hierarchical communication patterns, people can often feel suppressed as they communicate. This suppression of communication can lead to many untold and unknown stories.1,2 In the context of healthcare, the practical and implicative forces hold the hierarchy in place which then continues to keep many individuals’ stories silent.

Back to Top | Article Outline

Variable Communication Patterns

Another issue of healthcare communication is that communication patterns are highly variable due to the involvement of multiple professionals, cultures, individuals’ education levels, and technological communication components. In addition, healthcare professionals usually function in a time-constrained paradigm, which can lead to rushed communication interactions. The time constraint is due to the acute patient populations who are cared for, usually in need of emergent and urgent care. This type of environment leaves little, if no time for team reflection, or team processing as a collaborative action.

Back to Top | Article Outline

Team Learning

Team learning is yet another issue. In the acute healthcare setting, nurses and physicians rarely have communication learning opportunities together during their academic and or professional careers. This is due in part to the current educational process in many academic settings and the constraints of education dollars in the acute care setting.

Back to Top | Article Outline

Safe Space

Given healthcare’s pursuit of a culture of safety, healthcare team members need to be able to openly communicate for the sake of the patient. Open communication has to be developed and cultivated to sustain. To cultivate and sustain an open communication environment, it is imperative to create a safe space, where individuals can feel that they can openly communicate.3

The safe space is defined by the encouragement of open communication within an environment that protects the discussion from any punitive actions, redefines the hierarchically focused communication, and also removes the concerns of caring for a real patient. This safe space is created when the team of healthcare professionals acts as collaborators, are not judged, all have a voice of equal weight, and where they have time to reflect and initiate change in the realm of task, process, and the use of language.

With the use of a modified action research design, the simulation environment, and participant narratives,2 there is an attempt to create a safe space where a new collaborative communication exploration can be attained with a team of healthcare professionals.

Back to Top | Article Outline

RESEARCH QUESTIONS

  • Can the simulation environment be used to improve team communication, by helping the team to bring what are normally tacit activities into voice, making the tacit explicit?
  • Will the team use the simulation space to make changes for task, process, and language?
  • Can this simulation experience be developed as a model for improving healthcare team communication and interactions?
Back to Top | Article Outline

Method: Action Research, Narrative, and Coordinated Management of Meaning: The Action LU4T2

Three studies were developed using a modified action research design4 and the use of narrative in the form of participants’ stories.5,6 This is a modified action research design because the usual action research cycle has a linear process; in this cycle, the changes happen simultaneous or in parallel within the actual intervention as the participants have discussions and make decisions related to change. The reason for using this type of research design is to develop a place for the participants to be reflective together, where all of the team voices can be heard, acknowledged, and valued to develop an atmosphere of team collaboration.

Back to Top | Article Outline

The Settings and Participants

In acute healthcare, the operating room (OR) encompasses highly functioning teams, obvious time constraints, and has many layers of professional hierarchies. The OR can appear chaotic at times; however, the teams have a tacit ability to make order on their own terms. Thus, the OR and all of its specialty teams are prime examples and a place to identify potential team issues.

In the fall and winter of 2007/2008, the specialty OR teams of an acute care delivery system in the Midwest identified communication issues and the need to streamline processes within their daily routines. This was apparent from the perspective of the physician comments and team member observations shared in the format of formal satisfaction surveys and informal conversations with the principle investigator and administrative leadership of the medical center.

Importantly, the specialty cardiac, orthopedic, and general trauma OR teams were interested in working on their communication interactions. The healthcare system and medical center were supportive of the studies because of the current awareness of the importance of communication as related to improvements for patient safety. Because of the use of the actual ORs and staff time, a financial analysis was developed given this is an expensive and continually busy environment. The finance department of the medical center assessed the monetary commitment. They gave the recommendation that this process was worth the dollars that would be spent to accomplish the simulation periods. The dollars related to 2 hours of staff time and taking an OR off line for that time period. Fortunately, for the purpose of in-services and meetings, there was an established late start occurring weekly for this OR. This time was taken advantage of to complete the majority of the simulation periods.

Back to Top | Article Outline

Development of the Simulation Periods

Physician champions and staff team members were chosen to help develop the simulation scenarios. They were chosen because they heard about the project in staff and physician meetings, and they showed an interest in participating in the project. The physicians included surgeons from each specific surgical specialty, an anesthesiologist, the registered nurse (RN) OR manager and RN supervisor, and RN team leaders from the specific service lines of cardiac, general, and orthopedic surgery.

The study events were designed with the participants’ input; the principle investigator had several conversations over a period of months with the physician champions and participating staff. During the meetings, the team members were queried informally as to what they thought would be of importance related to patient care delivery situations, and current issues or problems. Their input was imperative so that they would engage in the process and find it beneficial to their particular needs related to team development and process improvement.

Back to Top | Article Outline

Participant Consent

All of the participants were asked to read and sign the participant research consent. Participation in the study was voluntary. The information obtained from the study was and is intended for positive change.

Back to Top | Article Outline

The Teams

The first study encompassed the 10 members of the cardiac team of the OR using the scenario of an emergent cardiac balloon pump insertion (ie, this is usually performed directly after cardiac bypass surgery when the patient cannot successfully be taken off the cardiac bypass pump). The second included a general surgery trauma team consisting of 32 individuals moving the patient from the emergency department through the surgical intervention. The third simulation study was completed with 19 members of the orthopedic surgical team using the scenario of a trauma patient surgical intervention in the OR. The study participants included physicians, nurses, OR technologists, one physician assistant, OR surgical assistants, and anesthesia aides. For the purpose of tracking, the OR surgical assistants and anesthesia aides are noted as ancillary personnel in the Table 1. As noted, the studies transpired in the OR medical center setting in the actual units and spaces.

Table 1

Table 1

Back to Top | Article Outline

Data Collection

The data collection was approached from the aspect of an action heuristic. The action heuristic was developed from an original concept taken from the communication theory of Coordinated Management of Meaning. The heuristic is known as the Lived stories-Untold stories-Unknown stories-Unheard stories-Untellable stories-Told-stories-Telling2 (LU4T2; in the Coordinated Management of Meaning, this is known and described as the LUUUUTT model by the developer Dr. Barnett Pearce; however, for the purpose of this discussion it is named as LU4T2). The LU4T2 was used to create a context for a narrative progression exploring the perception of the participants within 2-hour data collection periods. Each participant’s voice is a piece of the story within the context of the action LU4T2.

To do this, before each simulation period started, the participants were informed that anyone of them may stop the process at any point to ask a question, teach, or discuss a current or past issue. The researcher also used the space to stop the simulation in places when it was obvious that discussion was transpiring. When the process was stopped, the participants were asked to share the discussion in an effort to bring forth the voices of all of the team members. The simulation was used as a recall space to encourage positive discourse and dialog, which in these cases lead to team relationship building and positive care delivery change.

The simulation period provides a setting to develop collaborative communication praxis with the team and to gain insights into their current perceptions of task, process, and the use of language.

To capture the data, each session was video recorded and reviewed by the principle investigator and research assistants. There were two cameras running simultaneously at all times. One was used to capture the entire room or scene, and the other was focused on the specific conversations that transpired. Each tape was reviewed for the capture and recording of a task, process, or language discussion.

Back to Top | Article Outline

Defining Task, Process, and Language

The task was viewed as one element of a care delivery process such as obtaining a supply for patient care. A process encompassed the use of two or more tasks to complete a piece of care delivery. An example of a process was the completion of a blood transfusion for a patient. The process consists of the initial order, the laboratory work, the processing of the units of blood, obtaining the blood and bringing it to the actual delivery setting, the read backs to assure the correct blood product was present, and the actual delivery of the blood or transfusion. A language item was defined as the use of a word, sentence, or a nonverbal cue during a communication interaction.

Back to Top | Article Outline

Results/Findings

Cardiac Team

In using simulation in this qualitative way, the team is brought into a space of reflection and memory. During the cardiac OR study, the 10 team members/participants identified the need to standardize 16 items in total, 19% or three items related to task, 37% or six related to process, and 44% or seven identified as actual use of language. At times in the process, the team members were truly surprised that they had not recognized these things that they openly acknowledged would be easy to change within their usual daily routine. The team needed the space to act as a collective voice.

Being in the actual environment, they function daily, helped the team to have this type of recall, interaction, and realization to envision what could and should be changed to help them be more efficient and collaborative in their routines as a highly functioning team. Each participant had time to discuss their own unique ideas and to give voice and recognition to their thoughts; thus, bringing the tacit into voice.

They spent time discussing what it felt like to be a member of the cardiac team and the ideas they had about the meaning of collaboration. In addition, this situation gave them time to truly be with each other, present, and in the moment as listeners and collaborative meaning makers. This gave the team an opportunity to gain insight into their tacit team behaviors.

Back to Top | Article Outline

General Trauma Team

During the general team simulation, many developments occurred, which led to the recognition of 94 items that required attention, whether that was to completely change or simply alter a process. During this study, 23% or 22 items related to task, 62% or 58 related to process, and 15% or 14 items related to language. As related to the team relationships, having four physicians present with the team for 2 hours was a positive aspect of this research. Having the physicians spend the time with the team and having the physicians acknowledge, the team members as collaborators in this process gave the staff participants the sense that their voice was being heard as important contributors. The physicians and staff took advantage of the time together to share the moments to teach and reflect upon current practice and issues.

Some specific items the team discussed were related to in-line stabilization of the neck for patients with trauma, the timing and transfer of patients with trauma from the emergency department to the OR, blood transfusion protocol, designated trauma room and usage of the rooms, equipment storage, and team roles. The anesthesiologist had time to discuss his needs and explain why certain task designations were important at various places in the timing of events for a patient from a physiologic standpoint.

Back to Top | Article Outline

Orthopedic Trauma Team

During the orthopedic surgical simulation, the team identified 56 items. Of these items, 16% or nine related to task, 66% or 37 to process, and 18% or 10 to language. The orthopedic trauma simulation brought forth the importance of having time for the team to practice and organize when the team is in an emergent situation. The team recognized that when there is an emergent situation the team experience is greatly variable, dependent upon the situation and the team members that happen to be present. The orthopedic simulation offered a space for the surgeons to be able to do extensive teaching and to spend time with the team to create an understanding of why particular items are important to the care of the patient from again a physiologic standpoint.

During the simulation, a set of items were identified for future exploration as related to potential task and process change. The team identified the importance of disseminating information when changes are made so that the changes are understood and sustained.

From an observational perspective, the experience seemed to be good for many of the participants. At the end of the cardiac study, one nurse stated that the process “. . was the shot in the arm the team needed.” During the next study a previously skeptical surgeon said “I thought it was really terrific.” And, although the statements may sound corny, they convey that the experience was positive. To corroborate this notion, at the end of the process the fore mentioned trauma surgeon wanted to plan for another simulation to explore the entire process with the patient with trauma from the field to the intensive care unit. There were multiple comments made and caught on tape that reiterated these sentiments and more.

Back to Top | Article Outline

Consistent Findings

There are several consistent findings throughout all of the studies. First, the majority of items discovered and identified related to process (Table 2). Often a process is developed and then remains as stagnant and thus is not revisited, even when it is no longer functional within the environment.

Table 2

Table 2

Second, during all of the studies, the participating physicians discussed the need to be acknowledged when they have given an order. They want to know that their command was heard so that the team will be able to follow through with completing the process.

Third and next finding, related to the need to have individuals identify who they are concerning their profession and name. This is important so that each team member can readily communicate to assist the team with an overall dimension of order and follow through. When individuals do not identify themselves, there is no sense that anyone is actually there to assist and collaborate in a specific role.

The fourth finding related to the ideas of anticipation and critical thinking. Nurses are taught to be critical thinkers, to be proactive and anticipate what will be needed by the physicians. During varying times in a procedure, the physicians may be having a discussion that is unrelated to the needs at the moment. However, because of the physician conversation at the OR field, and given the nurses propensity to help, the nurse may be moved to think of something that is not really needed at that moment. In critical situations, in particular in the OR, each team member needs to verbally communicate what they are about to do as to clarify whether this should be the next step with other team members, so as not to do unnecessary things, to duplicate activities, to leave at a critical time, and or to waste time during a care delivery process.

The fifth finding had to do with equipment and supply location. It was evident from the findings of these studies that as medical centers grow and change often left out of the process is the necessary time to explore, using the concept of system engineering or human factors as related to the environment. Thus, as services, equipment, and tools are added to the continuum of care, enough time needs to be allocated to locate effective logistical aspects of storage, training, and simply the concept of practical application from the user standpoint.

Sixth and last finding is that the nurses and physicians used the qualitative simulation environment as a space to bring increasing equality to their assertion levels, which are normally felt as unequal and at times stilted. This type of simulation space encourages the creation of an opening in each other’s thought processes to be truly with7 the other person. In developing a sense of being with or attuned to the other, there is an actual growth process, which can occur when it comes to being able to sense what the other person may need in terms of the interactive quality of the relationship.8 This adds to one’s ability to learn how to convey important information in a collaborative manner.9 In these types of healthcare scenarios, the physicians and nurses because of their respective dominant and subordinate roles (ie, nurses are subordinate to physicians in the healthcare hierarchy) at times fall into unwanted repetitive patterns (URPs) in their communication. The URPs can inhibit discussion and collaborative behaviors. In addition, as the habitual URPs continue to be practiced, the relationship between the pair of communicators can be damaged because of derogatory and ineffective use of language.1,2 The simulation scenario can and does become a space for a communicative relationship repair. “The repair process is an interactive one requiring the openness of both people in attempts to reconnect . .” and to become attuned to each other8 as communicative compliments in a collaborative space.

In this research context, simulation was used to bring the physicians’ assertive levels down to an interactive component with the nurses’ and to encourage the nurses to be increasingly assertive to meet the physicians in a collaborative and interactive decision making space.

As a point of interest, when first approached, some of the participants were skeptical, because of the nature of this type of simulation as related to the development of collaborative communication. However, after experiencing the space of recall and recognition and seeing the team in an invigorated form, from the aspect of interaction and positive change, the participants are now supportive. They are now willing to participate in more qualitatively based simulations. What makes this type of simulation research work is simple; it is based in the notion that the team makes the magic of positive change through their ability to use recognition and recall. The simulation space provides the team with the environment to appreciate the complexity of their care delivery processes and to then influence and create positive change.

Back to Top | Article Outline

DISCUSSION

Social Construction

These studies are based in the ideas of social construction. Social construction simply put is that reality is defined by human interaction; the stories that are told become reality. If the stories can be discussed and team interactions can be developed in a positive way, a new reality of interactive and positive communication can be defined.6,10

Back to Top | Article Outline

Multiple Studies

To define positive communication, it was important to have multiple studies for a comparison of data, an environment, a simulation template, and a structured time allotment that works. So, the first use of the data comparisons will be explored to create communication interventions in the culture. These interventions are meant to redefine the communication within the hierarchy of relationships to promote increasingly open communication.

A second reason for developing three separate studies was to take time to view the four environments as unique from the aspects of cultural team healthcare delivery differences and dynamics. Although, the team settings could be viewed as similar because of the levels of patient acuity and process, they are culturally different because of the provider and healthcare delivery specialties and team interactions.

The third reason for creating three separate studies was to develop a template or tool, where positive communication could be changed and practiced for the betterment of safe patient care. Having comparisons of teams, which could be recreated in structured environments was important to the creation of a new simulation model for improving communication.

The fourth reason to develop these concepts as three distinct studies was to establish a template related to time. All of the data collection activities transpired in a standard of 2-hour time blocks during the simulation periods. This is an important development in the process given that there is an ostensible understanding in the healthcare delivery environment that time is a precious commodity because of financial and patient care delivery constraints.

Back to Top | Article Outline

Time to Define

The assumption is that if given the time and space, the team members can identify and define processes, which can positively effect and strengthen the care delivery team process. Simulation is an established method for practice in medicine for task development because it allows for a safe space, where patients are not at risk. Instead of using the patients in these simulations, high-fidelity mannequins are used to simulate the patient response. The difference with this particular type of simulation scenario is that in using the qualitative research frame, rather than the actual practice of an event, it is the interactions of the team and responses to each other, which are placed at the center of attention.

“Experiences can shape not only what information enters the mind, but the way in which the mind develops the ability to process that information.”8 The experiences the team members have within the collective team environment gives them each an understanding as to how the team learns to function.

Back to Top | Article Outline

Slowing the Environment Down

A great aspect in using simulation as a communication research exploration is that in the simulation environment, the healthcare delivery team has the ability to slow down the usual time-constrained processes. This gives the team participants time to explore many issues, which cannot occur safely during real patient care delivery scenarios because of time constraints in delivering care. This ability to slow the environment down is a key factor in developing a safe space, where the participants have time to recognize, recall ideas and events, using reflection.

Each team member has time to actually talk about what is important to each of them as related to their own particular professional roles within the context of the care delivery process. Akin to crew resource management, in this simulation context each voice is meant to be heard with equal weight and authority (Civil Aviation Authority. CAP 737: Crew Resource Management. Civil Aviation Authority, Safety Regulatory Group; 2006. Available at: www.globalaviation.com/cap737.pdf. Retrieved June 1, 2008). The team has time to recognize11 and make changes to their daily processes and to explore the underpinnings of the functionality of what they do every day, what they want to do and aspire to do.

Back to Top | Article Outline

Limitations

There are several limitations to these studies. There were inconsistent settings; although all in the OR department, there were actually varying OR suites used for each simulation. So, the actual environments were different as related to functional use, size, shapes, and supply configuration.

Another is that at the time of these studies, the principle investigator was the director over the units in the surgical services division. Although one wants to remain objective, as a human there is always an amount of subjectivity, which enters the process.

Given these are qualitative studies, people discuss what they think are important topics. Thus, there were no controls over the conversations and there were no control groups.

The data were sorted by the use of specified definitions. However, some of the items identified have several components and a decision had to be made as to where these items were best suited related to coding.

This is a new way of doing qualitative simulation research, so this is not a proven method to explore communication and process. However, in an effort to begin this type of exploration process, there had to be a first attempt to develop a template, which could potentially be reproduced.

Back to Top | Article Outline

Future Developments

New Curriculums

The findings will be used to develop new curriculums for healthcare team collaboration. The environments are busy, hold great variability, and appear chaotic at times, yet they have distinct structure and order. In an effort to develop this type of template for new team curriculums, the focus is placed on multiple types of situations during the healthcare delivery process, which at times do make for a perception of chaos and order simultaneously.

Back to Top | Article Outline

Tacit Team Voice

Another aspect of using simulation as a safe space is to be able to bring a newcomer on the team into the environment as a learning experience. During the healthcare delivery process, at times there is a tacit understanding, which occurs when teams are highly functional as a social construction. The social construction transpires and is built during the team interactions together. This social construction then becomes the team reality. The reality is functional for the team. In addition, the functionality is layered with experiences and encompasses then a hybridity of meanings.9,12,13

So, it is often difficult for a newcomer who has not been a part of the team’s social construction to acclimate into the communication dynamics of the team environment, and in particular within highly functioning healthcare teams. This type of situation occurs because the tacit behaviors have been repeatedly practiced in the relationships that teams develop and exhibit over periods of time together. It is here that simulation can be used to create an increased understanding of what is being identified as the tacit team voice.

Back to Top | Article Outline

Future Studies

Two similar institutional review board-approved studies have now been completed. One with the emergency department and OR neurosurgical team exploring a neurosurgical trauma intervention, and a broader study, which explored a trauma patient’s through put experience using the flight and ambulance crew, emergency department, OR, neurosurgical intensive care unit, and the medical surgical floor. The findings from these studies will be added to the current pool of data and concept to continue to develop this qualitative simulation model and research framework. The future questions to explore are:

  • How do healthcare teams develop their unique sense of order?
  • How do healthcare teams develop patterns of tacit communication, which elicit positive patient care delivery outcomes?
  • In particular, what do these healthcare team tacit communication patterns look like?
  • Can the healthcare team tacit patterns be purposefully recreated by the same healthcare team and or by other healthcare delivery teams?
Back to Top | Article Outline

Summary

By using reflexivity in the form of dialog, cojoint meaning making is developed as related to simulation as a process, tacit team activities, and learning to bring the tacit in to voice. Thus, the tacit becomes explicit. Each participant’s input unfolds as a link in the care delivery process. Together participants’ stories reveal an emergence of thematic findings, which create a presentation of the current temporal care delivery construct.

By developing increasing understanding of the healthcare delivery team environment through the use of simulation, the team can begin to dissolve the boundaries of hierarchies and socially constricted talk. It is here in the newly constructed communication space that the healthcare team can move from a current state of hierarchical boundaries and suppressive communications to an expectation of an openly interactive communicative space to promote safer patient

The more understanding that will be developed about individuals and teams as an ephemeral social construction within a particular environment, the greater the potential implications can be for practical change in the form of new constructions. In healthcare, simulation can be used within a qualitative research context to develop positive communication interactions within team environments for the creation of better care delivery translating into safer patient care.

Back to Top | Article Outline

REFERENCES

1. Forsythe LL. Healthcare Communication and the Creation of a Culture of Safety. Santa Barbara, CA: Fielding Graduate University; 2007.
2. Pearce WB. Making Social Worlds: A Communication Perspective. Malden, MA: Blackwell Publishing; 2007.
3. The Joint Commission. 2009 National Patient Safety Goals. IL: The Joint Commission; 2009.
4. Coghlan D, Brannick D. Doing Action Research in Your Own Organization. 2nd ed. Thousand Oaks, CA: Sage; 2005.
5. Clandinin DJ, Connelly FM. Narrative Inquiry: Experience and Story in Qualitative Research. San Francisco, CA: Jossey-Bass; 2000.
6. Pearce WB. Communication and the Human Condition. Carbondale, IL: Southern Illinois University Press; 1989.
7. Shotter J. The Role of ‘Withness’—Thinking in ‘Going on’ Inside Chiasmically—Structured Process. Organization Studies Summer Workshop: On Theorizing Process in Organizational Research, Santorini; 2005:12–13.
8. Siegel JD. The Developing Mind: How Relationships and the Brain Interact to Shape Who We are. New York: Guilford Press; 1999.
9. Sternberg RJ, ed. Wisdom: Its Nature, Origins, and Development. Cambridge, MA: Cambridge University Press; 1990.
10. Wittgenstein L. Philosophical Investigations. Translated by Anscombe GEM. Oxford: Blackwell; 1953.
11. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviation Psychol 1999;1:19–32.
12. Lather P. Getting Lost: Feminist Efforts Toward a Double(d) Science. Albany, NY: State University of New York Press; 2007.
13. Steier F. Cybernetics as … mutualling. Cybernet Hum Know 1992;1:3–10.
Keywords:

Simulation; Team communication; Qualitative research; Coordinated management of meaning

© 2009 Lippincott Williams & Wilkins, Inc.