JENNIFER BASARAB-TUNGABDOMINAL SURGERY ROTATION

Communication and Conflict Resolution in the OR

Why Is This Needed?

We as anesthesiologists sensed a need for improvement in mutual communication skills Surgical chiefs agree this need is present

Effective communication is one of the 6 core competencies that must be demonstrated for successful completion of residency

Poor teamwork and communication are key factors responsible for medical errors Poor communication identified as the root cause

of 35% of anesthesia-related sentinel events

Can Communication Be Taught?

Some might say “you can’t teach an old dog new tricks,” but…

Students are interested in learning about this… In a study that surveyed Iranian medical students, positive

attitudes toward learning communication skills were more prevalent than negative attitudes

Interestingly, positive attitudes were more prevalent and negative attitudes less prevalent in female medical students and those in the basic science portion of their training Indicates that we enter medical school knowing that

communication is important, but it seems to be lost on us later in our training

And specific interventions for physicians have been successful (see next slide)…

Teaching Communication Skills

In a 2011 study, oncologists were randomly assigned to a brief palliative care-focused communication skills training course using patient actors 11-hour workshop in small groups followed by 30

minutes of individual coaching Pre- and post-intervention assessments of skills Intervention improved communication skills

significantly and with moderate to large effect size Both global communication skills and skills with respect

to palliative care discussions were improved

Communication and Conflict

Breakdowns in communication are one of the most frequent causes of conflict in health care Unresolved conflict in turn creates an impediment to

communication and undermines the teamwork that is necessary for good patient care

The OR is at risk for conflict because: There are many different professionals with overlapping

and sometimes poorly delineated responsibilities Two physicians sharing equal responsibility for patient Complex, high-pressure work environment Sleep deprivation and stress affect interactions Ethical conflicts and conflicts of interest may emerge

Anesthesia-Related Sources of Conflict

Postponement/cancellation of cases How we communicate this to surgeons can potentially

have a positive or negative effect on how they perceive it

Some information is usually lost in the interactionChanging anesthesiologist assignment just

before the beginning of a caseDouble-coverage causing delays in induction

and emergence

Conflict Resolution in General

Five basic mechanisms of conflict resolution Avoidance – unlikely to be useful in the OR because

conflict is prevalent in this environment Yielding – one side acquiesces to the other;

appropriate when one party recognizes that they are in error

Collaboration – the preferred approach, which focuses on achieving goals together and is a “win-win” system

Compromise – both sides make trade-offs Competition – conflict is seen as a zero-sum game

that is won by one party and lost by the other

Conflict Resolution in the OR

Conflict resolution in the OR requires participation at the institutional and individual levels

Institutional: Establish an institution-wide conflict management

program Build a culture that welcomes normative conflict

resolution Foster group cohesion

Conflict Resolution in the OR (continued)

Personal: Anticipate conflict and develop communication skills Identify the precise source of the conflict Establish personal rules of conduct Emphasize shared standards and goals Find a nonjudgmental starting point for discussion Recognize shared frustrations with the system Conduct any necessary confrontation in a private

setting Have a low threshold for intervention by a third party Transfer patient care to an uninvolved colleague if

conflict is irreconcilable

Conflict Resolution in the Stanford OR

Per Dr. Cannon, the best way to resolve an ongoing conflict is to submit a SAFE report

SAFE reports are read by Dr. Cannon, Dr. Brodsky, or Dr. Fanning

Dr. Cannon can set up mediation-type meetings with individuals and between involved parties to help find a solution

Aggressive Behavior

Aggressive Behavior

Frustration-aggression hypothesis: aggression arises from the experience of being prevented from reaching an expected goal (frustration) Modulated by social learning and perceived intention Situational factors such as pain and hot temperatures make

aggression more likely Conversely, good communication skills can mitigate

aggressionIn the context of health care,

frustration comes in the form of feeling disrespected, not being listened to, and being treated unfairly Or perceiving any of these, independent of

actual presence

How to De-Escalate Aggression

Stay calm and respectful Approach in a warm, friendly,

open manner and avoid closed body language (crossed arms, standing too close)

Speak softly and clearly in short sentences while avoiding condescension

Maintain nonthreatening eye contact

Use facial expressions or nodding to convey attentiveness & understanding

Determine the right time to speak Wait for the heightened emotion to

recede before responding

Avoid distracting activities such as writing or looking at the computer

Show compassion and consideration

Ask open-ended questions to get the other person's point of view

Acknowledge frustration and the importance of the issue

Give a clear message that you understand and want to help

Explore solutions and provide choice whenever possible

Verbal and Nonverbal Communication Skills

Many of the de-escalation techniques mentioned above are simply elements of good communication Maintaining eye contact Avoiding closed posture such as crossed arms Speaking in calm, soft tones and avoiding “talking down” Conveying attentiveness with facial expressions and gestures Avoiding distractions Avoiding interrupting the other person

Practice these skills during any conversation, not only ones involving conflict and aggression

Psychology of Communication

Basic Functions of Communication in an Acute Medical Care Setting Build and maintain team structure Coordinate team process and task execution Exchange information Facilitate relationships

Four Aspects of a Message Content: Information about facts, objects, and events Self-revelation: Information about the sender as person Relationship: Information about the relationship between sender

and receiver Appeal to Act: Many messages tell the receiver how he or she is

supposed to actHelpful to keep in mind the functions and aspects of

messages in order to make your messages more effective

Nonverbal and Paraverbal Communication

Paraverbal communication Tone, pitch, and pacing of our voices

Nonverbal communication Gesture, posture, facial expression, and eye contact

These help the receiver understand the meaning of a message in its larger situational context Compared to words, they are much more colored by

attitudes and emotions and are less under conscious control

If verbal and nonverbal channels are incongruent, we will subconsciously place greater importance on the nonverbal and paraverbal cues. So it’s not always what we say that’s most important, but how we say it.

Dysfunctional Communication Patterns

Unspecified receiver “Could somebody…” or “we should…”

Poor speech patterns Speaking in a low voice or too hastily, mumbling, unfinished sentences,

strong dialect, poor grammarToo much information

Rapid presentation of info, minimal pauses, long lists, run-on sentencesToo little information

Abandoning explanations, not replying to questions, monosyllabic answers, periods of silence

Passivity or aggressiveness It is preferable to be assertive but not aggressive; e.g., use words to

express any anger you feel in a civil manner.Poor listening

Interrupting, diverting, debating, quarreling, tuning out, reactive behavior (defiance, refusal, intentional failure, aggression, arrogance)

Good Communication in Critical Situations

Communicate congruently (verbal, paraverbal, nonverbal) Be able to talk about communication failure and address it at the

right time Speak unambiguously – be clear in what your message is and who

you are addressing Close communication gap using readback/hearback (see next slide) Brief your team members so all are aware of the situation at hand Search actively for information Be assertive but not aggressive Listen actively:

Be patient and do not interrupt Ask questions Eye contact Paraphrase and mirror (e.g. “So you’re saying we haven’t assessed for

hyperkalemia and should check an ABG potassium now”) Be supportive of the person you are talking with

Standardization of Communication

Use standard terminologyEnsure that messages are clearly heard and

understood using callouts, readback, and hearback Callout: a concise statement in a defined terminology

E.g. “I’m going to defibrillate now; please charge to 200” Readback and hearback: aimed at verifying that both sender

and receiver understood what has been said E.g. assistant responds with “Charged to 200” (readback) and you

confirm with “Ready to defibrillate – clear!” (hearback)

Health care professionals tend to dismiss this procedure as unnecessary due to a lack of familiarity with it However, standardization can help reduce misunderstanding

in noisy and stressful situations

Teamwork

The OR is a team environment that requires good communication and collaboration between team members

Teamwork requires mutual respect and communication Briefing, ongoing observation, and debriefing help create a good

tone for team collaborationThe field of healthcare has traditionally neglected the

role of teamwork because: Deep-seated cultural issues (individualistic culture) Assumptions about the value of individual expertise Strongly hierarchical power relationships

A major problem is the lack of a shared understanding about necessity and forms of teamwork

Six components of team communication:

Situational awareness – where have we come from, where are we now, and where are we going?

Problem identification – requires all team members to be comfortable with speaking up voluntarily and without hesitation

Decision making – requires adequate diagnosis of the problem, generation of solutions, and assessment of chances of adverse outcomes

Workload distribution – delegation of assigned tasks so no single individual is overloaded

Time management – linked to situational awarenessConflict resolution – includes listening well,

acknowledging feelings, and building respect

Team Players

A successful team player can: Listen and participate actively Ask the right questions Hold an opinion but change his/her point of view if

necessary Assess and value the qualities of other team members

Similarly, assess what you can do best and where others have more experience

Keep to an agreement and identify with a task Be self-critical Solve conflicts in a constructive way 

Teams Under Pressure

In stressful situations, team members often behave in maladaptive ways: Information gathering is abandoned early No reflection on the problem No discussion about goals No search for alternative solutions Group pressure, suppression of disagreement Risk shift

If several physicians are in charge of an emergency without having a team leader, nobody perceives themselves as accountable for the outcome, so the tendency for risky decisions increases

Diffusion of responsibility Individuals fail to take action because they believe another individual will act

or have already done so) Lack of coordination

Be aware of these destructive patterns and fight them when you see them occurring

Summary

Communication is a key aspect of acute medical care in an environment such as the OR

Good communication skills can be taught Basic verbal and nonverbal communication skills can be used to

resolve conflicts and de-escalate aggressive behavior Nonverbal and paraverbal communication can be more important

than the verbal message Learning the psychology of communication helps us understand

dysfunctional communication patterns and correct them Standardizing communication via callout, readback, and hearback

help reduce misunderstandings Teamwork is essential to acute medical care Team members can behave in dysfunctional ways when stressed, so

it is important to understand and implement the elements of good team communication

And Finally…

Don’t overestimate your abilities! Just as calling for help is useful in a medical crisis, turning to others can assist in conflict resolution.

References

Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand 2005; 49: 898-901.

Goelz T et al. Specific training program improves oncologists' palliative care communication skills in a randomized controlled trial. J Clin Onc 2011 Sept; 29(25): 3402-3407.

Fazel I and Aghamolaei T. Attitudes toward learning communication skills among medical students of a university in Iran. Acta Med Iran 2011; 49(9): 625-629.

Katz JD. Conflict and its resolution in the operating room. J Clin Anesth 2007; 19: 152-158.

Sim MG, Wain T, and Khong E. Aggressive behaviour: Prevention and management in the general practice environment. Aust Fam Phys 2011 Nov; 40(11): 866-872.

St. Pierre M, Hofinger G, and Buerschaper C. 2008. Crisis Management in Acute Care Settings. Berlin: Springer.