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Publication Abstracts


Factors affecting nurse-surgeon object transfer: Video analysis of inter-professional communication and situation awareness in the operating theatre. 

Korkiakangas, T., Weldon, S-M., Bezemer, J., & Kneebone, R. (2014). International Journal of Nursing Studies.


Background: One of the most central collaborative tasks during surgical operations is the passing of objects, including instruments. Little is known about how nurses and surgeons achieve this. The aim of the present study was to explore what factors affect these routine-like tasks, resulting in fast or slow transfer of objects.

Methods: A qualitative video study, informed by an observational ethnographic approach, was conducted in a major teaching hospital in the UK. A total of 20 general surgical operations were observed. In total, 75 hours and 22 minutes of video data have been reviewed. In the present study, a subsample of 225 minutes has been analysed in detail using interactional video-analysis developed within the social sciences.

Results: Two factors affecting object transfer were observed: 1) relative instrument trolley position; 2) alignment. The scrub nurse’s instrument trolley position (close to vs. further back from the surgeon) and their alignment (gaze direction) impacts on the communication with the surgeon, and consequently, on the speed of object transfer. When the scrub nurse was standing close to the surgeon, and “converged” to follow the surgeon’s movements, the transfer occurred seamlessly and faster (< 1.0 second) than when the scrub nurse was standing further back from the surgeon and did not follow the surgeon’s movements (>1.0 second).

Conclusions: The smoothness of object transfer can be improved by the scrub nurse’s instrument trolley position, which enables a better monitoring of surgeon’s bodily conduct and affords early orientation (awareness) to the upcoming request (changing situation), and therefore an alignment with the surgeon. Object transfer is facilitated by the surgeon’s embodied practices, which can elicit the nurse’s attention to the request and, as a response, maximise a faster object transfer. A simple intervention to explore the significance of these factors could improve communication in the operating theatre.


Communication in the Operating Theatre


Weldon, S-M., Korkiakangas, T., Bezemer, J. & Kneebone, R. (2013).  British Journal of Surgery.


Background: Communication is extremely important to ensure safe and effective clinical practice. A systematic literature review of observational studies addressing communication in the operating theatre was conducted. The focus was on observational studies alone in order to gain an understanding of actual communication practices, rather than what was reported through recollections and interviews.

Methods: A systematic review of the literature for accessible published and grey literature was performed in July 2012. The following information was extracted: year, country, objectives, methods, study design, sample size, healthcare professional focus and main findings. Quality appraisal was conducted using the Critical Appraisal Skills Programme. A meta-ethnographic approach was used to categorize further the main findings under key concepts.

Results: Some 1174 citations were retrieved through an electronic database search, reference lists and known literature. Of these, 26 were included for review after application of full-text inclusion and exclusion criteria. The overall quality of the studies was rated as average to good, with 77 per cent of the methodological quality assessment criteria being met. Six key concepts were identified: signs of effective communication, signs of communication problems, effects on teamwork, conditions for communication, effects on patient safety and understanding collaborative work.

Conclusion: Communication was shown to affect operating theatre practices in all of the studies reviewed. Further detailed observational research is needed to gain a better understanding of how to improve the working environment and patient safety in theatre.


Video-supported Simulation for Interactions in the Operating Theatre (ViSIOT)

Korkiakangas, T., Weldon, S-M., & Bezemer, J. Kneebone, R. (2015). Clinical Simulation in Nursing.


This article introduces a data-grounded simulation model for training social interaction strategies to operating theatre nurses. Video-supported Simulation for Interactions in the Operating Theatre (ViSIOT) draws on original video-based research on teamwork in the operating theatres in the UK. The objective of the ViSIOT model is to improve verbal and non-verbal interactions between nurses and surgeons that often fall outside explicit training. These involve visual monitoring of colleagues, verbal responsiveness, speaking up about distractions, and seeking prompt clarification when needed. The model includes two scenarios and video-supported debriefing, which utilises authentic research footage from the operating theatres. In the paper, the strategies are briefly communicated and implications for training are discussed.



Unsettled teamwork: communication and learning in the operating theatres of an urban hospital

Bezemer, J., Korkiaknagas, T., Weldon, S-M., Kress, G., Kneebone, R. (2015). Journal of Advanced Nursing.


Aim To explore the unsettling effects of increased mobility of nurses, surgeons and other healthcare professionals on communication and learning in the operating theatre.

Background Increasingly, healthcare professionals step in and out of newly formed transient teams and work with colleagues they have not met before, unsettling previously relatively stable team work based on shared, local knowledge accumulated over significant periods of close collaboration.

Design An ethnographic case study was conducted of the operating theatre department of a major teaching hospital in London.

Method Video recordings were made of 20 operations, involving different teams. The recordings were systematically reviewed and coded. Instances where difficulties arose in the communication between scrub nurse and surgeons were identified and subjected to detailed, interactional analysis.

Findings Instrument requests frequently prompted clarification from the scrub nurse (e.g. ‘Sorry, what did you want?’). Such requests were either followed by a relatively elaborate clarification, designed to maximize learning opportunities, or a by a relatively minimal clarification, designed to achieve the immediate task at hand.

Conclusions Significant variation exists in the degree of support given to scrub nurses requesting clarification. Some surgeons experience such requests as disruptions, while others treat them as opportunities to build shared knowledge.


Sequential Simulation (SqS): an innovative approach to educating GP receptionists about integrated care via a patient journey – a mixed methods approach

Weldon, S-M., Ralhan, S., Paice, E., Kneebone, R., Bello, F. (2015). BioMed Central Family Practice.


Background An evaluation of an effective and engaging intervention for educating general practice (GP) receptionists about integrated care and the importance of their role within the whole system was conducted.

Methods Workshops took place in North West London, one of England’s 14 ‘Integrated Care Pioneers.’ Three training days featuring Sequential Simulations (SqS) were held. Forty GP receptionists attended on each day, as well as 5–6 patients and 8–9 healthcare professionals. The SqS developed was from a collection of patient stories, the key scene of which featured a GP receptionist. The scenes were designed to show the consequences for the patient of professionals working in silos. This provided the focus for facilitated table discussions. The discussants suggested ways in which an unfortunate series of events could have been dealt with differently. These suggestions were then incorporated in a re-designed SqS. Evaluation was conducted through questionnaires, field notes and analysis of video material. Descriptive statistics and thematic analysis were applied.

Results Ninety three participants responded to the questionnaire out of 131 attendees. All (93/93) respondents reported that the event was a powerful learning experience and that they had gained confidence in improving patient care. 98 % (91/93) reported that their knowledge of integrated care had improved. The simulation was rated highly as a learning experience [60 % (57/93) - excellent, 39 % (37/93) good]. Further evidence of educational benefit was expressed through comments such as: ‘The simulations really got me thinking about the patient as a human with many problems and situations.’

Conclusion SqS is an innovative and practical way of presenting current care pathways and health care scenarios in order to create a shared focus, engage the emotions of the participants and bring the principles of integrated care to life. Facilitated table discussions are an opportunity to see events from multiple perspectives, share reactions and ideas, and practise co-producing service reforms with patients. We believe this approach is a useful way of preparing front-line staff to participate in integrated care.


Music and communication in the operating theatre

Weldon, S-M., Korkiakangas, T., Bezemer, J. & Kneebone, R. (2015). Journal of Advanced Nursing.


Aims To observe the extent and the detail with which playing music can impact on communication in the operating theatre.

Background According to the cited sources, music is played in 53-72% of surgical operations performed. Noise levels in the operating theatre already exceed World Health Organisation recommendations. There is currently a divide in opinions on the playing of music in operating theatres, with few studies conducted and no policies or guidance provided.

Design An ethnographic observational study of teamwork in operating theatres through video recordings. Quantitative and qualitative data analysis approaches were used.

Methods This study was conducted between 2012–2013 in the UK. Video recordings of 20 operations over six months in two operating theatres were captured. The recordings were divided into music and non-music playing cases. Each case was logged using a request/response sequence identified through interactional analysis. Statistical analysis, using a χ2, explored the difference between the proportion of request repetitions and whether music was playing or not. Further interactional analysis was conducted for each request repetition.

Results Request/response observations (N = 5203) were documented. A chi-square test revealed that repeated requests were five times more likely to occur in cases that played music than those that did not. A repeated request can add 4-68 seconds each to operation time and increased tensions due to frustration at ineffective communication.

Conclusions Music played in the operating theatre can interfere with team communication, yet is seldom recognized as a potential safety hazard. Decisions around whether music is played and around the choice of music and its volume, are determined largely by surgeons. Frank discussions between clinicians, managers, patients and governing bodies should be encouraged for recommendations and guidance to be developed.



A Video Analysis of Intra- and Interprofessional Leadership Behaviors Within “The Burns Suite”: Identifying Key Leadership Models

Sadideen, H., Weldon, S-M., Saadeddin, M., Loon, M., Kneebone, R. (2016). Journal of Surgical Education.



Objective Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). The authors recently published the concept of “The Burns Suite” (TBS) as a novel simulation tool to deliver interprofessional and teamwork training. It is unclear which leadership behaviors are the most important in an interprofessional burns resuscitation scenario, and whether they can be modeled on to current leadership theory. The purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS.

Methods A total of 3 burns resuscitation simulations within TBS were recorded. The video analysis was grounded-theory inspired. Using predefined criteria, actions/interactions deemed as leadership behaviors were identified. Using an inductive iterative process, 8 main leadership behaviors were identified. Cohen’s κ coefficient was used to measure inter-rater agreement and calculated as κ = 0.7 (substantial agreement). Each video was watched 4 times, focusing on 1 of the 4 team members per viewing (senior surgeon, senior nurse, trainee surgeon, and trainee nurse). The frequency and types of leadership behavior of each of the 4 team members were recorded. Statistical significance to assess any differences was assessed using analysis of variance, whereby a p < 0.05 was taken to be significant. Leadership behaviors were triangulated with verbal cues and actions from the videos.

Results All 3 scenarios were successfully completed. The mean scenario length was 22 minutes. A total of 362 leadership behaviors were recorded from the 12 participants. The most evident leadership behaviors of all team members were adhering to guidelines (which effectively equates to following Advanced Trauma and Life Support/Emergency Management of Severe Burns resuscitation guidelines and hence “maintaining standards”), followed by making decisions. Although in terms of total frequency the senior surgeon engaged in more leadership behaviors compared with the entire team, statistically there was no significant difference between all 4 members within the 8 leadership categories. This analysis highlights that “distributed leadership” was predominant, whereby leadership was “distributed” or “shared” among team members. The leadership behaviors within TBS also seemed to fall in line with the “direction, alignment, and commitment” ontology.

Conclusions Effective leadership is essential for successful functioning of work teams and accomplishment of task goals. As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation. Furthermore, attempting to map these behaviors on to leadership models can help further our understanding of leadership theory. Collectively this can aid the development of refined simulation scenarios for team members, and can be extrapolated into other areas of simulation-based team training and interprofessional education.

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