Safer Surgery part 34 ppsx

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anaesthesia is also only partially represented. The specialized eld of activity for
the anaesthesiologists is thus more realistic than for the other occupation groups.
Since the content of the communication is determined by specialist activity, in
this study we investigated only the anaesthesiologists’ communication, not that
of the surgeons or the nursing staff.
Anaesthesia simulators, like most ight simulators, are high delity simulators.
These offer the advantage of allowing a relatively standardized way of observing
how incidents are dealt with. Complete standardization is not possible, because the
behaviour of the anaesthesiologists inuences the further course of the incident.
The analysis of such scenarios thus faces the same problems as does problem-
solving research with highly complex computer-simulated scenarios (see Dörner
et al. 1983).
Behaviour in simulator scenarios can already deviate from real operation
situations because, in calm beginning phases, the participants are more prepared
for critical events during an operation. Additionally, at least at the beginning,
the participants are aware that they are in an observation situation. For this
reason, utterances that often occur in calm phases of real operations, like jokes,
lessons, and private conversation (Pettinari 1988), are rarely heard. Despite these
limitations, physiologically and as an operation setting for anaesthesiologists, the
simulator is at least apparently valid. In the scenarios we used (cf. Section 2.3), the
anaesthesiologists exhibited a high degree of involvement which was conrmed in
self reports (St Pierre et al. 2004). This high degree of the participants’ involvement
during ‘hot phases’ of the scenario suggests that here they used their customary
communication strategies, especially to coordinate with the nursing staff and
surgeons.
Research Questions
The study presented here investigated how anaesthesiologists in critical situations
in the simulator communicate with their nursing staff and the surgeons. The focus
of the investigation is on the analysis of the anaesthesiologists’ utterances arose

during the processed scenarios, focussing on communication. This includes the
organization of behaviour and the coordination of the team: establishing shared
mental models, conveying and requesting information, dening goals, planning,
deciding, control, conict management, reection, etc. Special attention is paid to
the interaction with the surgeons. Here, we pursued three issues:
Description of the Communication (Exploratory, Descriptive Question) Since
there are so few studies of communication in operations, we rst investigated
what general kinds of utterances arise in the processed scenarios. A focus is on
communication related to problem solving.
We were also particularly interested in nding out whether clinical experience,
gender or the kind of scenario had an inuence on the kinds of utterance.
Observing Team Problem Solving and Communication in Critical Incidents
305
Connection between the Categories of Communication and the Quality of
Medical Management (Hypothesis-testing and Exploratory Question) The
results of human factors research in other occupational elds permits us to
deduce the hypothesis that the quality of medical management is connected
with communication. We therefore ask: how does the communication behaviour
of anaesthesiologists differ under good and bad medical management in the
scenarios?
Quality of Communication in Critical Situations (Exploratory Question, Normative
Approach) During the scenario’s critical situations, the communication was
evaluated in terms of previously formulated behavioural expectations (behavioural
markers): did the anaesthesiologists exhibit the type of communication behaviour
that psychological and medical experts would expect in a team problem-solving
process?
Method
Data Background: The Training Study ‘Human Factors in Anaesthesia’
With cooperation between the Simulator Centre of the Anaesthesia Clinic at
Erlangen University Clinic and the Institute for Theoretical Psychology, a

curriculum for physicians training for their specialization, ‘Human Factors in
Anaesthesia’, was developed (St Pierre et al. 2004). This combined previously
introduced simulator training for crisis management and psychological training
modules on specic human factors topics. The psychological trainers are also
involved in the feedback about the processing of anaesthesiological crisis
scenarios in the simulator. For the rst module, ‘communication and cooperation
in the OR’, three scenarios were developed that made specic demands on team
problem solving and communication while dealing with incidents. This made it
possible to evaluate not only the medical competence of the participants, but also
their team-related problem-solving competence. Thus, the desirable integration
of non-technical abilities (e.g., communication in an interdisciplinary team)
and specialized procedures (e.g., stabilizing blood pressure) was achieved.
The rst module of the curriculum was evaluated in an experimental design
with a test group and a control group. The control group received a lecture on
human factors in anaesthesia instead of the training unit. They worked through the
same simulator scenarios. For a more detailed presentation of the study and of the
training evaluation, (see St Pierre et al. 2004). The scenarios both groups worked
through in the course of training were used for the evaluations presented here,
because few differences were to be expected within the training (any differences
are highlighted in this chapter).
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Sample
The participants in the study were 34 interns at the University Clinic for
Anaesthesiology in Erlangen. This was a random sample, except that women
and men were distributed evenly between the two groups and among the training
sessions. Because the sample was small, the participating women worked through
Scenario 2 whenever possible. This means that the effects of sex and scenarios
are confounded, but recognizable. Despite the partly chance allotment, it was
possible to obtain homogeneous partial samples, with the exception that the

individual scenarios were differently lled in terms of the sex and experience of
the participants. Clinical experience ranged from one to six years with a mean
of 3.3 years. Men and women did not signicantly differ in their mean length of
clinical or in simulator experience.
Scenarios Used
For the training programme, the following scenarios were developed so as to make
specic demands not only on the management of a medical incident, but also on
problem solving and communication in the team. Each scenario (detailed below)
was designed to take 30 minutes (the actual duration of the scenarios ranged from
16 to 42 minutes).
The training programme’s three scenarios were each worked through by one
participant, each supported by a real nurse. Simulator staff assumed the role of the
surgeon, sometimes supported by a participant. The scenarios are based on a script
that calls for fairly standardized communication from the instructed role-players in
predetermined critical situations. For example, after a drop in blood pressure, the
surgeon asks one of the anaesthesiologists whether he or she ‘isn’t managing back
there’. If the participant ignores the question, the script prescribes as the surgeon’s
Men Women Total sample
N 22 12 34
Years of clinical experience 3.4 3.1 3.3
Proportion of participants with
simulator experience
68% 42% 59%
Scenario 1 11 1 12
Scenario 2 1 10 11
Scenario 3 10 1 11
Table 18.1 Sample of the sample
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307
‘answer strategy’ that he or she ‘exert verbal pressure’. But if the anaesthesiologist

communicates a problem, the script instructs to offer cooperation.
The participants judged all three scenarios to be adequately realistic and to be
stressful. On a ve-step Likert scale (1 = very realistic, 5 = not realistic at all),
the means for evaluated realism were between 1.8 and 2.55 (n.s.); on a ten-step
Likert scale (1 = boredom, 10 = overburdening), the stress caused by the scenario
was reported as between 5.3 and 7.6 (n.s.). While extreme stress would deteriorate
participants’ ability to problem solve whereas boredom would mean that they did not
experience a critical situation (but instead routine), the medium stress levels reported
seems to indicate that participants were challenged but not working at their limit.
Scenario 1: Laparoscopic Cholecystectomy with Volume Deciency Reaction and
Air Embolism
In a laparoscopic cholecystectomy, the abdominal cavity is lled with CO
2
gas
to provide the surgeon with better visibility. If the abdomen is inated too much,
less blood can ow back from the abdomen to the heart, resulting in lower blood
pressure and a faster pulse. This is the rst complication in the scenario. After
the therapy, which requires close communication between the surgeon and the
anaesthesiologist, operative inattention leads to bleeding in the abdominal
cavity. CO
2
gas ows into the bloodstream and results in an air embolism. The
anaesthesiologist must recognize this situation, which is acutely life-threatening
for the patient, and plan the therapy, in which the surgeon must be integrated.
The therapy consists in administering medications that stabilize circulation and,
if appropriate, changing the operating procedure, organizing transesophageal
ultrasound and transfer to the intensive care unit (ICU).
Scenario 2: Occluded Perforated Abdominal Aorta Aneurysm
This clinical picture is an aneurysm of the main artery in the upper abdomen (acute
intense pain). The aneurysm tears or bursts, resulting in a life-threatening situation.

This is the situation in this case.
The anaesthesiologist must rapidly coordinate the operating procedure in
close discussion with the surgeon and the nursing staff and attempt to stabilize
circulation with the aid of providing volume (blood, infusions) and medications
supporting circulation (catecholamines). Special communicative demands arise if
clamping off is too fast or if the surgeon opens the aorta. In the end, the patient
should be sent to the intensive care ward in a stable state.
Scenario 3: Lung Embolism after Speculum Examination of the Knee in the
Recovery Room
This scenario is about a postoperative complication resulting from vascular
congestion. The clinical picture develops suddenly when the bloodstream carries a
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blood clot (thrombus) into the lung, where it blocks a blood vessel. Thus, a section
of the lung is no longer supplied with blood, and no gas exchange occurs here. The
blood backs up to the heart and the heart muscle is acutely overburdened, resulting
in circulatory failure and intense pain.
The anaesthesiologist is called to a patient (who has had a knee operation)
as an emergency and must familiarize him or herself with the situation, collect
the necessary information and then organize the therapy. Treatment includes
rstly, applying medications that support circulation, anaesthesia and respiration
and thereafter, medications that reduce blood clotting. But, the use of such a
thrombolytic after surgery must be discussed with the surgeon. For the severity of
the embolism and the state of therapy to be judged, a number of specialists must
be brought in and their judgements discussed.
Observation Evaluation Tools
The analysis of the scenarios is based on the methods of evaluation described in
the following:
a system of categories, ‘problem solving in a team’
behavioural markers for specic communication behaviours

experts’ judgement of medical management.
A Tool for Observing Problem Solving in the Anaesthesia Team
A system of categories, ‘problem solving in a team’, was developed to categorize
everything uttered in each scenario. It comprises 24 categories organised into ve
‘overarching categories’ labelled: (i) formal characteristics of the statement, (ii)
organization of activity, (iii) relation the team and of processes, (iv) conict management
and (v) other. The development of the system was oriented toward the phases of action
organization, as developed by Dörner (1996), and toward considerations emerging
from research on solving complex problems in groups (e.g., Stempe and Badke-
Schaub 2002, 2003). It was supplemented by inductive category formation on the
basis of video data from the anaesthesia simulator. Every remark was classied on
the formal level and in one of the other four overarching categories. Randomness-
corrected observer agreement on these categorizations reached 61 percent–80 percent
(Cohen’s Kappa). Table 18.2 shows the overarching and subsidiary categories.
Behavioural Markers for Specic Communication Behaviour
Behavioural markers for communication were developed. Behavioural markers
are behaviour patterns whose presence in a stream of behaviour indicates certain
skills. For the present evaluations, anaesthesiologists and psychologists developed
a set of behavioural expectations based on the scenario scripts. Studies using
•
•
•
Observing Team Problem Solving and Communication in Critical Incidents
309
behavioural markers often report low inter-rater reliability, but for our project,
which aims to evaluate a training programme, a high concordance between
observers was essential. So, we decided to formulate a set of very specic markers.
They describe communicative behaviour required to solve a scenario optimally,
for example the insistence on a slow de-clamping in the aorta aneurysm scenario.
A list of behaviour-oriented observable items was developed that operationalizes

the necessary communication competencies.
The demands of each scenario were different, so 16 to 22 different markers
were dened for each scenario. Two observers judged the presence of each marker
in each person in the scenario (possible answers: yes, no, not applicable). The
randomness-corrected observer agreement here was 82 percent (Cohen’s Kappa).
This shows that it is easier to achieve good inter-rater reliability using more specic
markers (but of course, the marker set has to be dened for every scenario that is
evaluated). Examples for the behavioural markers used are shown in Table 18.3.
Experts’ Judgement of Medical Management
Two anaesthesia experts also independently judged the medical management of
the scenarios. The experts were not aware that the videos were being evaluated in
Overarching category Categories
Formal characteristics
Question, statement, directive/order, other
New unit of activity, addressing the sur
geon on own
initiative
Organization of activity
Information gathering, model formation, conveying
information (facts), decision, explanation of own
activity, commentary on activity
, conveying pr
oblem
and situation, conveying problem and situation
with model, redundance, control, conrming
understanding, hypothesis, anticipation, goal, plan
Relation to team and process
Utterances related to team and relationship, process
or
ganization

Reection/emotional utterances/own feelings
a
Conict management
Offer to engage in conict;
b
anaesthesiologist:
objective, escalating, ignoring, de-escalating
Other
a Because pure utterances of reection were not expected, these categories were bundled
together.
b This is the only category that considers the surgeon’
s utterances, because a conict always
arises from interaction. All utterances that could be considered offers to engage in conict were
counted.
Table 18.2 Category system ‘Problem solving in a team’
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accordance with the aforementioned tools. Differing observations were discussed
until agreement was achieved (communicative validation, e.g., Bauer and Gaskell
2000). For each phase of each scenario, a system was used in which points were
given for quality of therapy, diagnostics, and, where applicable, monitoring. Each
item could be scored from 0 to 2 points (bad to very good), which resulted in
scores between 16 and 24 points for the scenarios. Table 18.4 shows the eight
evaluation items for Scenario 1.
Some Results
As studies on problem solving or the analysis of thinking processes in the medical
eld are rare (but see Gaba 1992), we started with explorative questions. We were
able to formulate hypotheses concerning the eld of communication. We would
like to highlight some of the ndings of our analysis that helped us improve our
training programmes. In short:

Critical situation in
accordance with script
Behavioural marker
Scenario 1
Before the OP
Gives the OK for the OP only after his/her
own preparations are completed
Changed position (head
raised, feet lower
ed)
Anaesthesiologist conveys concern to the
surgeon early
Anaesthesiologist asks for a change of
position/release of pressure
Scenario 2
Cut
R
equests rapid clamping or conveys
problem
Asks the surgeon to report
Clamping
Intermediate brieng with nurse
Improvement of circulation conveyed to
surgeon
Scenario 3
Anaesthesiologist
enters r
ecovery room
Anaesthesiologist asks nurse what has
happened

Responsible superior is informed
Surgeon r
ejects heparin
Anaesthesiologist remains objective
Anaesthesiologist conveys reasons (acute
danger to patient, life takes priority over
knee … vital problem)
Table 18.3 Examples of behavioural markers for evaluating communication
in the scenarios used
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311
Anaesthetists talked more often than they expected they would across all
scenarios.
Almost half of all utterances help pacing or establishing shared mental
models.
We found nearly no explicit addressing of the team.
There was nearly no talking about aims and plans (of more than one step).
There were very few real questions.
We found a high correlation (.56) between the quality of clinical management
and communication measured with the behavioural markers.
In reporting some results, we will give the explorative questions that lead us in
the analysis followed by the answer.
Description of Communication
Amount and Type of Utterances
How much do the participants talk, and what kind of remarks do they make? The
anaesthesiologists spoke more during the scenarios than even they themselves
expected: in preliminary talks, the intention to investigate communication during
operations was repeatedly belittled as senseless on the grounds that there is little
speaking during an operation (which also contradicts our observations of operations).
There was a mean of 228 utterances per person; with an average scenario duration

of 28 minutes, that is 8.2 utterances per minute. The sample showed no difference
between men and women in the amount spoken. Utterances in the form of orders
– an average of 25.4 per scenario – account for almost a tenth of all utterances.
There were 31.3 questions asked per scenario. In terms of content, it should be
considered that the proportion of genuine questions is much lower, because many
directives are clothed in the form of a question (‘Would you hold the bag?’). Table
18.5 shows the distribution of these formal categories in the scenarios.
The formal categories showed no signicant differences between the scenarios,
sexes, or experience – nor any interaction between the factors. This nding is
surprising, because it seems to mean that anaesthesiologists in the simulator
•
•
•
•
•
•
Acute phase 1 (pneumoperitoneum
with circulatory reaction)
Acute phase 2
(discr. venous
bleeding)
Acute phase 3 (air embolism)
A
naesthesia
introduced
(0–2Pt)
Differential
diagnose
(0–2Pt)
Therapy

(0–2Pt)
Therapy
(0–2Pt)
Diag.
standard
(0–2Pt)
Diag.
advanced
(0–2Pt)
Therapy
circulation
(0–2Pt)
Therapy
breathing
(0–2Pt)
Table 18.4 Items for evaluating medical management (Scenario 1)
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312
utter a certain number of utterances of a specic kind. This should be further
investigated.
Proportion of Utterances Aiming at Team Coordination and the Establishment of
a Shared Mental Model
How much of what is said relates to the coordination of team activity and the
establishment of shared mental models? Here we looked at the categories:
conveying information; thinking out loud; conveying problems (facts only);
conveying problems with an explanation or model; explanation of one’s own
activity; redundance; conrming understanding; addressing the surgeon
(anaesthesiologist’s initiative).
An essential factor in successful problem solving is establishing shared
mental models. This process cannot be completely observed, but there are

utterances that explicitly suggest the intention of improving a shared mental
model (e.g., conrming understanding; explanation of one’s own activity) and
some that can help the other team members in ‘pacing’ (e.g., thinking aloud;
conveying information). The importance of these tasks for problem solving
is reected in the frequency of such utterances: the anaesthesiologist says
something that can contribute to team coordination a mean of 108 times per
scenario, almost four times per minute. This corresponds, in the mean, to
almost half of all utterances (47 percent). But a mean of only 18 utterances were
explicitly related to establishing shared mental models (conveying problems
with explanation; explanation of one’s own activity; conrming understanding).
Table 18.6 shows the distribution among categories that we regard as helpful
in or as aiming directly at constructing shared mental models. As with the
categories of action organization, there are enormous individual differences.
The frequency of redundance seems to indicate the anaesthesiologist’s intense
safety awareness.
In these categories, we found there are no differences in relation to experience
or sex.
Category Question Directive/
order
Statement/
utterance
Other/
filler
phrases
Utterances
total
Mean 31.6 25.5 162.5 8.2
227.9
Minimum 10 2 89 0
126

Maximum 75 62 349 26
433
Table 18.5 Formal characteristics of utterances in the scenarios
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313
Utterances Concerning the Team and the Team Problem-solving Process
How much of what is said relates to the team and the process of working together?
We counted the categories: reection or emotional utterance; references to
relationships; process.
A large part of the speaking is devoted to coordinating activity (especially
with the nurse); but very few utterances are directly related to the team. In the
scenarios, only the relationship to the surgeon was thematized, usually to draw
boundaries (in the sense of ‘Don’t interfere with my work, I don’t try to tell
you what to do, either’), seldom to underscore the shared team task (e.g., ‘Now
we have to manage this together’). Reection on the problem-solving process
was bundled together with utterances of one’s own emotional state (e.g., ‘Here
I’m not so sure, either…’), because we expected (and found) few self-reective
utterances in the sense of strategy evaluation. Utterances related to the work
process (‘Let’s do this now one step at a time’) accounted for a mean proportion
of 5 percent; this is less than one would expect for ‘good team achievement’ (see
Table 18.7).
Interestingly, there was virtually no communication about goals or plans (less
than 1 percent of all utterances). This may be due to the pressure of the situation,
or it could indicate a learning need for team problem solving. The individual
differences are substantial in the categories of team and problem-solving process,
but women and men do not signicantly differ in their use of these categories
(p=.360, t=.93; df=32). Nor do experience or the scenario type lead to signicant
differences in these categories (F=2.04; p=.15; and F=0.17; p=.84).
Category Mean Minimum Maximum
Conveying information 16.6 4 42

Thinking out loud 14.0 1 68
Conveying problems (facts) 22.4 5 49
A
ddressing surgeon on own initiative
9.4 0 34
Conveying problems with explanation 4.7 0 11
Explanation of own activity 7.5 0 15
Conrming understanding 5.8 0 16
Redundance 27.8 2 49
T
otal 1
11.3 49 203
Table 18.6 Utterances related to team coordination and shared mental
models