Safer Surgery part 24 ppsx

Safer Surgery
204
or the patient’s condition. Specically, on the individual level, relevant factors
include technical competence, heterogeneous knowledge (Rosen et al. 2008),
high work commitment (Nyssen et al. 2003) and a variety of attitudes towards the
interpersonal aspect of one’s work and the effects of stress on performance (Flin
et al. 2003). On the team level, anaesthetic teams are mostly crew-like (Arrow
et al. 2000, Tschan et al. 2006) – structured with traditional hierarchies, varying
size, sometimes no previous experience as a team and almost no formal training
in teamwork or interaction with one another. Finally, the context of anaesthetic
teamwork usually includes highly structured organizations and the necessity to
be attentive to a range of tasks (Leedal and Smith 2007). Tasks are characterized
by routine procedures as well as by rapidly shifting priorities, requiring the
handling of high risks where failures can potentially endanger human life. Thus, as
suggested by functional models of teamwork (Hackman and Morris 1975, Marks
et al. 2001, Wittenbaum et al. 2004), team and task variants inuence clinical
team performance via the interaction of the anaesthetic team members. Hence,
this interaction requires coordination in order to realize effective clinical team
performance (Dickinson and McIntyre 1997, Tschan et al. 2006). Besides individual
medical skills, experience and patient factors, coordination within the team is a
crucial factor inuencing the quality and timeliness of a reaction to unexpected
complications. This coordination requirement can actually be exacerbated by the
crew structure (e.g., MacMillan et al. 2004). In other words, without appropriate
coordination and effective communication beyond hierarchical constraints,
the team interaction could cause process losses which in turn would negatively
impact team performance (Marks et al. 2002, Steiner 1972). The following section
outlines mechanisms of anaesthesia team coordination.
Adaptive Coordination in Anaesthesia Teams
Coordination Requirements in Anaesthesia Teams
Performing joint actions requires coordination in the sense of orchestrating the
‘sequence and the timing of interdependent actions’ (Marks et al. 2001, p. 363).

However, it is not only the coordination of actions but also the coordination of
information (e.g., sharing information regarding a patient’s allergy and discussing
its implication for medication) that is important for clinical performance (Arrow et
al. 2000). For example, failure to appropriately communicate relevant information
(e.g., patient allergies) to all team members is a frequently reported incident in
anaesthesia (Catchpole et al. 2008) and problems in information transfer are
generally well known in the domain of healthcare (Cook et al. 2000, Murff
and Bates 2001). This might be due to the fact that in medicine, task-relevant
information is often unshared and has to be obtained either from the patient, other
team members, written notes or from several monitors in the operating room.
Measuring Coordination Behaviour in Anaesthesia Teams
205
These complex information requirements (Hirokawa 1990) pose high demands on
team coordination.
After having dened what has to be coordinated during team interaction,
questions arise on when – during interaction – specic coordination is appropriate.
As stated above, anaesthesia is characterized by routine as well as by non-routine
procedures in the sense of rapidly shifting priorities. In non-routine situations,
teams have to manage unexpected and unfamiliar problems potentially endangering
the system or outcome (Waller et al. 2004). This is a signicant point as a non-
routine event (NRE) in anaesthesia is by the denition of Weinger and Slagle
(2002, p. S59) ‘any event that is perceived by care providers or skilled observers
to be unusual, out-of-the-ordinary, or atypical’. NREs include critical incidents as
well as a broad range of events that might not lead to immediate adverse outcomes
but nevertheless could be early heralds of post-operative patient outcomes (Oken
et al. 2007). A recent survey in anaesthesia has shown that NREs occur in 30.4
per cent of reported cases (Oken et al. 2007). By their very nature, NREs are likely
to be ill-dened problems resulting from ambiguous cues and therefore requiring
diagnostic effort to dene the problem. Interestingly, studies from a comparable
domain, aviation, showed that non-routine situations require more communication

than routine situations (e.g., Orasanu 1993). The question arises as to how these
results can be transferred to anaesthesia and how anaesthetic teams can coordinate
actions and information adaptively to routine and non-routine situations.
Adaptive Coordination
Team adaptation means a change in team performance in response to a salient cue
leading to a functional outcome for the entire team (Burke et al. 2006). For example,
teams perform better when their members adapt their role behaviour in response
to unanticipated change (LePine 2003) or when they change leadership behaviour
depending upon the level of routine of a situation, the degree of standardization or
experience of team members (Künzle et al. in press). As Manser and co-authors
(2008) pointed out, adaptive coordination occurs on different organizational
levels. Adaptability has been found to be fundamental to establishing safety
(Salas et al. 2007b) and has been examined as one of the core components of
effective teamwork and a prerequisite for coordination (Salas et al. 2005). In
our work, we focused on adaptive coordination on the team level and argue that
adaptability can be considered a coordination process in and of itself rather than
simply a prerequisite to coordination. Similar to contingency models of leadership
(e.g., Fiedler 1964), the concept of adaptive coordination implies that different
coordination mechanisms are appropriate in different situations. The core idea
of adaptive coordination lies in the dynamic use of coordination mechanisms in
accordance with the workload of a given situation (Entin and Serfaty 1999, Grote
et al. 2004, Rico et al. 2008, Salas et al. 2007a, Serfaty and Kleinman 1990). Here,
workload describes a relationship between available resources such as information
processing capacity and task demands (Byrne et al. 1998, Young et al. 2008) and
Safer Surgery
206
refers to how a given situation is perceived by the person facing the task (Grote
et al. 2003). However, it is not only the coordination behaviour in either routine
or non-routine situations which is linked to team performance. Rather, it is the
adaptive transition from routine to non-routine and vice versa which seems to have

signicant effects on team performance (Waller et al. 2004). The question then
arises of how coordination should be changed in the adaptive transitions and by
which behavioural means it can be executed.
Means of Adaptive Coordination
Within the literature on team coordination, scholars have differentiated between
explicit and implicit coordination mechanisms (Entin and Serfaty 1999, Espinosa
et al. 2004, Kolbe and Boos 2009, Grote et al. 2003, Wittenbaum et al. 1998, Zala-
Mezö et al. 2009).
Explicit coordination is behaviour that is intentionally used for the
purpose of team coordination and mostly executed by means of verbal
or written communication (Espinosa et al. 2004, MacMillan et al. 2004,
Wittenbaum et al. 1998) or by transferring information and resources upon
request (Serfaty and Kleinman 1990) and can be used prior to or during
team interaction (Wittenbaum et al. 1998). In medicine as well as in other
high reliability contexts, a typical form of explicit pre-coordination is
standardization of behaviour through rules (Grote et al. 2004). During the
interaction, the team process can be explicitly coordinated by mechanisms
such as commands or afrmations (Marsch et al. 2004). It was found
that healthcare teams which successfully treated a cardiac arrest showed
more explicit coordination than poorly performing teams (Marsch et al.
2004). Explicit coordination can also be used to support group decision
processes, for instance by repeating task-relevant information (Kolbe
2007). Explicit coordination is clear and generally understandable but
involves communicative effort and time. It can be executed by every team
member on every hierarchical level or in the sense of shared leadership.
Implicit coordination is postulated to be primarily based on shared
cognition and on the anticipations of the actions and needs of the team
members (MacMillan et al. 2004, Rico et al. 2008, Serfaty and Kleinman
1990, Toups and Kerne 2007, Wittenbaum et al. 1996) and is also related
to team situation awareness (Manser et al. 2008, Salas et al. 2005). In a

recent study of anaesthesia teams, it was found that transactive memory
(knowing who knows what) predicted team members’ perceptions
of team effectiveness, and also affective outcomes such as team
identication and job satisfaction (Michinov et al. 2008). Compared to
explicit coordination, implicit coordination is less time intensive, but is
only effective if the team members have not only shared but accurate
mental models of the task and the team interaction. If one of these two
•
•
Measuring Coordination Behaviour in Anaesthesia Teams
207
requirements is not met, reliance on implicit coordination can be very
risky. This is in line with the proposals by Wittenbaum et al. (1998) who
postulated that implicit coordination can be ineffective in complex and
interdependent tasks. They suggested that the more coordination required
(e.g., divergent goals, unequal information distribution, ambiguity of
opinions and preferences), the more group members need to coordinate
explicitly. In fact, explicit coordination has been considered to be a
prerequisite of implicit coordination (Orasanu 1993). Given the fact that
both implicit and explicit team coordination modes have advantages
and disadvantages, the suggestion is that they be used according to the
situational demands (Grote et al. 2004). However, in medical teams there
seems to be an inherent preference for implicitness as the silver bullet of
coordination styles and reluctance against being explicit. As Heath and
colleagues (2002) observed in operating theatres, team members would
rather unobtrusively encourage others to perform certain actions with
the underlying assumption that explicitly asking them for assistance or
consideration was inappropriate or would interrupt activities in which
they were already engaged. This tacit assumption that ‘the more implicit
the communication, the more effective it is’ could be problematic in non-

routine situations where explicit coordination is required (Wittenbaum
et al. 1998). To ensure that such needs for explicitness are identied, it
seems that heedful interrelating can be a useful mechanism of adaptive
team coordination.
The idea of heedful interrelating was introduced by Weick and Roberts (1993)
and has received considerable attention. It includes certain attitudes and behaviours
towards the team and the situation in order to act in close alignment with situational
and team requirements. Being a heedful team member implies being mindful of
the team goal and one’s own contribution to it (Dougherty and Takacs 2004). This
means that while being heedful, the team members constantly reconsider their
own contributions in relation to the team goals (Grommes and Grote 2001, Weick
and Roberts 1993). It also means that rather than acting only habitually, team
members act purposefully with regard to the joint situation (Dougherty and Takacs
2004) and are well aware of how their actions t into the overall team goal (Wears
and Sutcliff 2003). This form of mindfulness is especially relevant for complex
and tightly coupled systems (Vogus and Welbourne 2003). Recent research results
have shown that heedful interrelating mediates the relationships of trust in team
members and monitoring by team members with future team performance (Bijlsma-
Frankema et al. 2008). Heedful interrelating consists of three different actions:
(1) the individual contribution by providing own actions, (2) the representation
of the system of joint actions and (3) the nal interrelation or subordination of
own actions within the envisaged system (Dougherty and Takacs 2004, Grommes
and Grote 2001, Weick and Roberts 1993). Thus, heedful interrelating is related
to the anticipation of the needs of other team members but can be regarded as a
Safer Surgery
208
coordination mechanism that goes beyond mere implicit coordination because it
can allow team members to identify needs for explicit coordination (Grommes and
Grote 2001). For instance, one team member might realize that his or her own or
someone else’s actions are not in line with the team goal and therefore the work

process has to be reorganized. Heedful interrelating also extends team orientation
(see Salas et al. 2005), because the latter is conned to an attitudinal preference
for working with others and enhancing individual performance while working
with others. Furthermore, heedful interrelating can prevent team members from
narrowly following protocols or from over-learned responses (Wears and Sutcliff
2003) and might allow team members the exibility to speak up when necessary
which in turn enhances learning and adaptability (Edmondson 2003), as well as
the overall effectiveness of the team.
Still, some authors argue that heedful interrelating refers to a way in which
behaviour is enacted rather than to the behaviour itself (Druskat and Pescosolido
2002). In line with this, only a few studies have analysed concrete behaviours or
communication by which heedful interrelating could be enacted (Cooren 2004,
Grommes and Grote 2001, Grote et al. 2003, Zala-Mezö et al. 2009). A recent
study on coordination in anaesthesia teams showed that heedful interrelating
occurred more in situations of high workload than in low workload phases (Zala-
Mezö et al. 2009). Thus, we need to know more about the interplay of explicit
and implicit coordination and how heedful interrelating facilitates the adaptive
transitions between these coordination modes.
Measuring Adaptive Team Coordination Behaviour in Anaesthesia
The objective of our current research on anaesthetic team coordination is to gain a
broad perspective of anaesthetic team behaviour coordination during routine and
non-routine and relate it to clinical performance. This requires detailed analyses of
team processes which have proven to be costly in both time and effort. However,
some authors suggest that not doing these analyses would be even more costly
because one would then be forced to forego key information regarding comparative
team dynamics and adaptation behaviours (McGrath and Altermatt 2002). As
Weingart (1997) concluded, gaining knowledge regarding what anaesthetic teams
actually do, how they complete their work and the resulting levels of success
increased our understanding of which processes (in this case, coordination)
inuence group performance, specically clinical effectiveness. However,

measuring explicit and implicit team coordination as well as heedful interrelating
is far from being a straightforward endeavour that allows us to draw on a variety
of existing methods. Even though implicit team coordination has been analysed
experimentally (Wittenbaum et al. 1996) and by using self-report measures (Rico
et al. 2008), studies on behaviour observations of implicit coordination are rare
(Entin and Serfaty 1999, Grote et al. 2003, Kolbe 2007, Serfaty et al. 1993, Zala-
Mezö et al. 2009), a fact that might be due to the tacit nature of implicitness.
Measuring Coordination Behaviour in Anaesthesia Teams
209
Thus, the necessity to investigate effective and adaptive team coordination and the
lack of suitable observation methods led us to develop a taxonomy of explicit and
implicit team coordination and heedful interrelating behaviour.
Taxonomy of Explicit and Implicit Team Coordination and Heedful Interrelating
Behaviour
The taxonomy we developed for our research on adaptive coordination in anaesthesia
teams consists of three main categories: explicit and implicit coordination, heedful
interrelating and other behaviour (Figure 13.1). The main category of explicit and
implicit coordination includes two sub-categories: coordination of information
exchange and coordination of actions (Arrow et al. 2000). Within these sub-
categories we differentiate explicit from implicit coordination mechanism, as shown
in Figure 13.1.
The applied taxonomy was developed to measure coordination
mechanisms with regard to explicitness, implicitness and heedfulness. Its strength
lies in the precise yet practical description of behaviour patterns specically found
in anaesthesia teams.
The subcategories were developed in an iterative process based on previous
work (Grote and Zala-Mezö 2004, Grote et al. 2003, Grote et al. 2004), on team
coordination literature (Arrow et al. 2000, Bowers et al. 1998, Espinosa et al.
2004, Kolbe 2007, Marks and Panzer 2004, Marsch et al. 2004, Rico et al. 2008,
Salas et al. 2005, Serfaty et al. 1993, Serfaty and Kleinman 1990, Toups and Kerne

2007, Tschan et al. 2006, Wittenbaum et al. 1996, Wittenbaum et al. 1998), and
on literature regarding heedful interrelating and related concepts (e.g., Bijlsma-
Frankema et al. 2008, Dougherty and Takacs 2004, Druskat and Pescosolido
2002, Grommes and Grote 2001, Rhee 2006, Toups and Kerne 2007, Vogus and
Welbourne 2003, Weick and Roberts 1993). Table 13.1 gives denitions and
examples of these coordination mode categories.
Data were coded using INTERACT (Mangold 2007), a coding software which
allows for marking and coding events within a digitalized video without the need
for transcribing the communication. In order to analyse the dynamic coordination
process and determine whether a certain coordination act is followed by another
coordination act and how long each act lasts, focal sampling (observing the whole
group for a specied amount of time such as the induction to anaesthesia) and
continuous coding are required (Bakeman 2000, Bakeman and Gottman 1986,
Martin and Bateson 1993). However, in doing so, the procedure of (1) dening
coding units (amount of behaviour that is assigned to one category) and (2) coding
these units into categories were confounded because the coding units are dened
with reference to the categories (McGrath and Altermatt 2002), a practice which
usually impairs the reliability of an observation method (Kolbe 2007). But, since
there were no appropriate unitizing rules for verbal and non-verbal interaction, we
had to dene the coding units as utterances or actions by a team member that t
into a single category.
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210
Figure 13.1 A taxonomy of explicit and implicit team coordination and heedful interrelating behaviour
Note: Coding units are here dened as utterances or actions by team members that t into one category (Bales 1950, Beck and Fisch 2000, Marby
and Attridge 1990). For each act, the actor, the target, and the duration are coded.
Behaviour of the anaesthetic
team member
Explicit & implicit coordination Heedful Interrelating
A

ttention
focus
on the joint
situation
Com-
prehension of
implications of
unfolding
events
Providing
unsolicited
task-relevant
action
Offers of
assistance
Indications of
satisfaction
with fulfilment
of task
Monitoring
Declaring own
needs
A
ssistance
requests
Approval
Planning and
procedural
q
uestions

Verification
questions
Questioning
decision
Providing
actions
upon request
In-process
decisions
Initiating
actions
Making plans
A
ssigning
tasks
Giving orders
Coordination
of actions
Provide
unsolicited
task-relevant
information
Obtaining
unsolicited
task-relevant
information
Listening
Requests for
information
Providing

information
upon request
Verifying
information
A
cknowledge-
ment
Summary
Questioning
information
Explicit
Implicit
Explicit Implicit
A
uthoritarian
behaviour
Silence and
action
Silence and no
action
Chatting
Technical alarm
Talking to patient
Broad
boundaries o
f
envisaged
system
Focusing on
representation

of others
Watching the
actions of
other team
members
Verbalising
own
behaviour
Verbalising
interpretation
of a situation
Correcting
behaviour of
other
team
members
Considering
others
Teaching
others
Giving
feedback in a
positive
manner
Giving
feedback in a
negative
manner
Considering
the future

Considering
external
conditions
Note making
Incom-
prehensible
communication
Others
Coordination of
information exchange
Measuring Coordination Behaviour in Anaesthesia Teams
211
Category Definition Example
Explicit coordination of information exchange
Requests for information
Checklist questions asked of
team members or questions
addressed to the patient.
‘Where’s the debrillator?’
‘Do you have any
allergies?’
Providing information
upon request
Includes answering direct
questions. I
nformation is given
only in response to direct
questions.
‘The debrillator is right
behind you.’

Verifying information
Includes repeating information
or giving verbal conrmations
regarding fullled actions.
‘Electrodes are checked.’
Acknowledgements
Includes verbal statements
indicating one has heard or
understood given information.
‘Okay
.’
‘
Um hm.’
Summary
Includes statements regarding
state of affairs or processes.
‘W
e had an asystole in
reaction to laryngoscopy.
We treated it with atropine
and 30 seconds of heart
massage.’
Questioning information
I
ncludes statements expressing
doubts about the accuracy or
source of information.
‘Are you sure he has no
aller
gies?’

Note making
Coded when a team member
lls out the patient’s chart.
Implicit coordination of information exchange
Pr
oviding unsolicited
task-relevant information
Providing information without
being asked to do so.
‘Blood pressure is okay.’
Obtaining unsolicited
task-relevant information
Includes actively garnering
information without being
asked to do so.
Reading patient’
s chart.
Listening
Includes obviously and
attentively listening to another
team member or patient with
undivided attention.
Explicit coordination of actions
Assistance requests
Include explicitly asking for
help.
‘Can you help me with
this?’
Table 13.1 Denitions and examples for categories
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212
Category Definition Example
Giving orders
Include directives, commands,
or instructions.
‘Can you hold this?’
‘Give him the fentanyl.’
Assigning tasks
Coded when subtasks are
assigned to team members.
‘I’ll intubate, you watch the
monitor
.’
Making plans
Include verbalizations of
non-immediate considerations
regarding what should be done
and when.
‘When we’ve nished
intubation we’ll call for an
OR nurse.’
Initiating actions
Include statements or
behaviours which initiate
actions (not orders or
decisions).
‘We could give him more
fentanyl.’
In-pr
ocess decisions

I
nclude statements of decision
such as dening timing of
intubation initiation.
‘We can intubate now
.’
Providing actions upon
request
I
ncludes behaviour that is
performed because asked to
do so.
After the physician
has asked the nurse to
administer the fentanyl, the
nurse accepts the order and
administers the drug.
Questioning decisions
Occurs when somebody
expresses doubts concerning a
decision, order or proposal.
‘
A
re you sure you want to
intubate right now?’
V
erication questions
Include somebody asking a
question to make sure they are
about to do the right thing.

‘I’ll start now
, is that
alright?’
‘You’ve already
administered the atropine,
right?’
Planning and procedural
questions
I
nclude questions concerning
procedure and further courses
of action.
‘How much fentanyl do
you want me to give?’
Appr
oval
Includes short verbalizations
of acceptance in reaction to a
proposal.
‘Good idea.’
Implicit coordination of actions
Pr
oviding unsolicited
task-relevant actions
Include task-relevant actions
completed without being asked
to do so.
After the physician
announces he/she is going
to intubate, the nurse holds

out the laryngoscope.
Table 13.1 Continued
Measuring Coordination Behaviour in Anaesthesia Teams
213
Category Definition Example
Offers of assistance
Coded when somebody verbally
offers help.
‘Can I help you with this?’
Indications of
satisfaction with
fullment of task
I
nclude statements of general
agreements.
‘F
ine.’
‘Okay
.’
‘Good.’
Monitoring (patient or
machine)
Codes when a team member
checks the monitor or behaviour
of the patient.
Reading indicators on a
monitor
.
Declaring own needs
Includes verbal statements

expressing personal need for
something (without asking
another person for it).
‘I
don’
t have gloves.’
‘I’m so thirsty.’
Heedful interrelating
Watching actions of other
team members
Coded when a team member
observes the actions of his/her
colleagues.
Team member watches
what another team member
is doing.
V
erbalizing own
behaviour
Occurs when personal
task action is verbally
communicated.
‘
I’m calling the attending.’
‘
I’m turning the alarm
down.’
Verbalizing interpretation
of a situation
Includes declarations or

assessments of a situation.
‘That was close!’
‘Now he seems to feel
better
.’
Correcting behaviour of
other team members
I
ncludes actions that correct the
behaviour of a colleague.
‘No, you should plug it in
here.’
Considering others
Includes attention given to
another’
s condition inuencing
task fullment.
‘Are you okay?’
‘Thanks.’
Teaching others
Includes detailed explanations
or demonstrations beyond the
mere correcting of a behaviour
of another team member.
‘The way you did that
wasn’
t wrong but it’s easier
if you do it this way.’
Giving feedback in a
positive manner

I
ncludes friendly reassurances
to a team member.
‘That was a very good
reaction.’
Giving feedback in a
negative manner
Includes providing feedback in
a less-than-sincere manner
.
‘This was not too bad.’
Considering the future
Includes considering the
consequences of personal or
other’
s actions.
‘We have to be careful
with this tube because we
have to put him in a prone
position afterwards.’
Table 13.1 Continued