Safer Surgery part 27 doc

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in anaesthesia crews in clinical and simulated work environments. Furthermore,
we were able to establish a relationship between certain coordination patterns and
clinical performance ratings for a specic anaesthetic crisis in a simulator scenario.
In a current project (see also Chapter 13 by Kolbe et al. in this book), we
continue the task-analytic approach to adaptive coordination in anaesthesia crews.
This research aims at improving instruments and procedures for team performance
assessment by comparing and potentially integrating two observation systems for
coordination behaviour. The focus of this project is to empirically evaluate the
predictive power of two different observation systems for coordination processes
with regard to non-technical skills and clinical performance assessments. Because
many assessments of healthcare professionals’ work, especially in critical situations,
are only possible in a simulator environment, we continue a research strategy using
both clinical and simulated research settings to best develop the strengths and counter
the limitations associated with either setting. The results of this study will provide an
important contribution to improving systems used to assess coordination as a central
aspect of team performance. If team performance cannot be assessed accurately,
efforts to dene specic training needs and to improve team performance may be
futile (Manser 2008). In order to dene specic competencies that team training
should address, to monitor progress, and to nally assess competence, research
needs to establish a link between specic behaviours and patient outcome.
Acknowledgements
This research was funded by the Swiss National Science Foundation (PBZH1-
100994). We thank the clinical staff at the VAPAHCS, especially the cardiac team
and the staff at the Patient Simulation Center of Innovation, for their support in
conducting this research. The ongoing study referred to in this chapter is funded
by the Swiss National Science Foundation (SNF 100013-116673/1).
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Chapter 15
Teams, Talk and Transitions in Anaesthetic
Practice
Andrew Smith, Catherine Pope, Dawn Goodwin and Maggie Mort
Introduction
Effective communication skills are required for the practice of anaesthesia as they
are for any branch of clinical medicine. Despite their importance in practice (Kopp
and Shafer 2000, Smith and Shelly 1999) and training (Harms et al. 2004), published
work tends to deal with formal, explicit teaching of specic skills such as patient
handover (Solet et al. 2005). Communication with patients takes place preoperatively
when the anaesthesiologist rst meets the patient, on induction of anaesthesia,
during surgery (if the patient is conscious), on emergence from anaesthesia and
again with the patient postoperatively. Communication also takes place between
members of the anaesthetic team – by which we mean anaesthesiologists, their
assistants and the recovery room staff. What anaesthesiologists say at these points
has seldom been formally studied, and does not feature in traditional textbook
teaching on anaesthesia, but seems instead to be learned as part of the informal
‘unofcial syllabus’ of anaesthetic knowledge (Smith 2007). Further, the issue

of how communication is shared between anaesthesiologists and other members
of the anaesthetic team does not appear to have been explored. In this chapter
we will present data from the Lancaster anaesthetic expertise study, looking at
communication between members of the anaesthesia team at a number of transition
points: induction of anaesthesia, emergence from anaesthesia and handover of the
patient in the recovery room.
Methods
The approval of the local research ethics committees was granted for this study,
and written informed consent obtained from patients being cared for by the
anaesthesiologists under observation. The study was conducted principally in a
medium-sized district hospital in the north-west of England, with shorter periods
of observation at a university hospital in the south-west of England. We adopted an
ethnographic approach, grounded in detailed observation (Atkinson et al. 2001),
followed by a series of in-depth interviews. Ethnography is often used for the
in-depth study of complex phenomena within the social context they occur and,
Safer Surgery
242
as in this study, typically combines a range of methods including observation,
interviews and documentary analysis (Pope 2005, Savage 2000). The Lancaster
study aimed to explore the ways different types of knowledge are acquired and used
in anaesthetic practice. It focused mainly on the operating theatre environment,
and included observation of and interviews with anaesthesiologists, operating
department practitioners (ODPs)
1
and nurses working in the operating theatre and
recovery room (Pope et al. 2003, Smith et al. 2003a). Operating sessions were
purposively sampled to cover a range of different types of surgery and anaesthetic
practice and levels of anaesthetic expertise.
Most commonly, an individual anaesthesiologist was observed during the
course of a routine operating theatre session. We also focused on physical areas,

such as the recovery room, and on operating lists where trainer–trainee interactions
were taking place. All anaesthesiologists and operating theatre staff were aware
of the study. The anaesthesiologists taking part all had the opportunity to decline
to be involved either in the study as a whole or in individual observation. The
researcher would obtain consent before each observation session. Typically,
observation started in the anaesthetic room before the patient arrived and, in
some but not all cases, continued until after the patient had been transferred
to the recovery room. Conversation between all those in the anaesthetic room
– patients, members of the anaesthesia team, surgeons and others who entered
the room during this time – was recorded in the form of near-verbatim notes.
Observation further continued to include emergence from anaesthesia and then
the handover to the recovery room nurse. The researchers recorded, with note
book and pencil, the events, talk and behaviour of the anaesthesiologists and
other anaesthesia personnel. They aimed to capture the complexity of anaesthesia
practice. Immediately after the observation session, these were expanded and
annotated, then transcribed for analysis. The interviews we conducted were
carried out on a purposively selected cross-section of anaesthesia personnel
– physicians, nurses and ODPs.
The analysis was directed towards classifying the communication which
occurred at induction, emergence and handover and began with individual close
readings and annotations of the observational transcripts by all members of the
project team, looking for recurring patterns of talk, behaviour and interaction.
These were subsumed into broader categories and themes (Silverman 2001).
Discordant data – instances where observed or reported communication differed
from the norm or was deemed to be inappropriate in some way – were noted
and discussed in detail. Such cases usually stand out in the analysis as they
appear contradict the emerging explanation of the phenomena under study and
they therefore help to rene the analysis by focussing attention on aspects of the
1 The operating department practitioner is a grade of theatre staff unique to the
UK. Their two/three-year training course prepares them for three aspects of theatre work:

assisting the surgeon, assisting the anaesthesiologist and working in the theatre recovery
room.
Teams, Talk and Transitions
243
data which might otherwise have gone unnoticed. Differences in communication
between expert and inexperienced practitioners were deliberately sought and
examined. These can be especially valuable when a phenomenon such as tacit
knowledge in anaesthesia is being studied, as this knowledge may be more easily
visible when it is poorly developed or still being formed, as in the observation
of trainees at work. The aim of ethnographic research is to produce an account
of what is being observed that makes sense to the participants being studied – to
get ‘under the skin’ of what is going on (Pope 2005) and to develop concepts or
analytical categories that can be applied to other settings, rather than to produce
statistical generalizations. Typically such studies have smaller samples (Silverman
2001, Pope et al. 2000) and a judgement is made that sufcient data have been
collected when further analysis of new data yields no new categories or emerging
themes (‘data saturation’: Miles and Huberman 1994). To check the accuracy of
our interpretations and ndings, some of the research participants were invited
to examine the analysis and to tell us if the picture we presented of anaesthetic
practice reected their own experiences and understandings.
Results
Approximately three observation periods were carried out per month over one
year, yielding a total of 39 sessions comprising 133 hours of data. At the time
we made our observations, there were 12 consultant anaesthesiologists in the
department and ten trainees. We observed all but one of the consultants at least
once. Of the 31 observations in the operating theatres at the primary site, 13 were
of consultants working alone, 12 were a consultant/trainee pair and 6 were of
trainees working alone. Nineteen interviews were conducted (Smith et al. 2003a)
with anaesthesiologists, anaesthetic and recovery nurses. These interview data
were used to supplement and cross-reference the ndings from the workplace

observation, which was the main focus of our inquiry.
The study as a whole illuminated, for the rst time, the interplay of different
types of knowledge in professional anaesthetic practice, and how such knowledge
is acquired and used. Apart from the general aspects of anaesthetic expertise, we
have also been able to draw out more specic aspects of expertise in relation to
the use of electronic monitoring (Smith et al. 2003b), regional anaesthesia (Smith
et al. 2006a) and the denition and reporting of critical incidents (Smith et al.
2006b), as well as enlightening the sociological discourses of human–machine
interaction and distribution of work in interprofessional settings (Goodwin et al.
2005, Mort et al. 2005).
For the purpose of this chapter, we focus on observations of the induction of
general anaesthesia on 54 occasions, and of 31 patients emerging from anaesthesia.
(The imbalance here arose from the fact that the observers were primarily following
the anaesthesiologist, and many patients had been handed over to recovery room
personnel before emergence (waking up) from the anaesthetic (Smith et al. 2005)).