communication and conflict resolution in the or-revised

8/2/2019 Communication and Conflict Resolution in the or-Revised

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J E N N I F E R B A S A R A B - T U N G

A B D O M I N A L S U R G E R Y R O T A T I O N

Communication and Conflict

Resolution in the OR


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Why Is This Needed?

We as anesthesiologists sensed a need forimprovement in mutual communication skills

Surgical chiefs agree this need is present

Effective communication is one of the 6 corecompetencies that must be demonstrated forsuccessful 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


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Can Communication Be Taught?

Some might say you cant 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 thannegative attitudes

Interestingly, positive attitudes were more prevalent and negativeattitudes less prevalent in female medical students and those in thebasic science portion of their training

Indicates that we enter medical school knowing that communication isimportant, but it seems to be lost on us later in our training

And specific interventions for physicians have beensuccessful (see next slide)


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Teaching Communication Skills

In a 2011 study, oncologists were randomly assignedto a brief palliative care-focused communicationskills training course using patient actors

11-hour workshop in small groups followed by 30 minutes ofindividual coaching

Pre- and post-intervention assessments of skills

Intervention improved communication skills significantly andwith moderate to large effect size

Both global communication skills and skills with respect topalliative care discussions were improved


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Communication and Conflict

Breakdowns in communication are one of the mostfrequent causes of conflict in health care

Unresolved conflict in turn creates an impediment tocommunication 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 andsometimes 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


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Anesthesia-Related Sources of Conflict

Postponement/cancellation of cases

How we communicate this to surgeons can potentially have apositive or negative effect on how they perceive it

Some information is usually lost in the interaction

Changing anesthesiologist assignment just before thebeginning of a case

Double-coverage causing delays in induction and

emergence


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Conflict Resolution in General

Five basic mechanisms of conflict resolution

Avoidance unlikely to be useful in the OR because conflictis 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 onachieving goals together and is a win-win system

Compromise both sides make trade-offs

Competition conflict is seen as a zero-sum game that iswon by one party and lost by the other


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Conflict Resolution in the OR

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

Institutional:

Establish an institution-wide conflict management program Build a culture that welcomes normative conflict resolution

Foster group cohesion


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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 isirreconcilable


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Conflict Resolution in the Stanford OR

Per Dr. Cannon, the best way to resolve an ongoingconflict 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 finda solution


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Aggressive Behavior


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Aggressive Behavior

Frustration-aggression hypothesis: aggression arisesfrom the experience of being prevented from reaching anexpected 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 aggression

In the context of health care,

frustration comes in the form offeeling disrespected, not being listenedto, and being treated unfairly Or perceiving any of these, independent of

actual presence


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How to De-Escalate Aggression

Stay calm and respectful Approach in a warm, friendly,

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

Speak softly and clearly in short

sentences while avoidingcondescension Maintain nonthreatening eye

contact Use facial expressions or nodding

to convey attentiveness &understanding

Determine the right time tospeak Wait for the heightened emotion

to recede before responding

Avoid distracting activities suchas writing or looking at thecomputer

Show compassion andconsideration

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


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Verbal and Nonverbal Communication Skills

Many of the de-escalation techniques mentionedabove 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, notonly ones involving conflict and aggression


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Psychology of Communication

Basic Functions of Communication in an Acute MedicalCare 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 act

Helpful to keep in mind the functions and aspects ofmessages in order to make your messages more effective


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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 amessage 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 willsubconsciously place greater importance on the nonverbal andparaverbal cues. So its not alwayswhatwe say thats mostimportant, but howwe say it.


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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 grammar

Too much information Rapid presentation of info, minimal pauses, long lists, run-on sentences

Too 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 toexpress any anger you feel in a civil manner.

Poor listening Interrupting, diverting, debating, quarreling, tuning out, reactive

behavior (defiance, refusal, intentional failure, aggression, arrogance)


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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 youre saying we havent assessed for

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


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Standardization of Communication

Use standard terminology Ensure that messages are clearly heard and understood

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

E.g. Im 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 youconfirm with Ready to defibrillate clear! (hearback)

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

noisy and stressful situations


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Teamwork

The OR is a team environment that requires goodcommunication and collaboration between teammembers

Teamwork requires mutual respect and communication

Briefing, ongoing observation, and debriefing help create a good tonefor team collaboration

The field of healthcare has traditionally neglected therole 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 understandingabout necessity and forms of teamwork


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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 membersto be comfortable with speaking up voluntarily and

without hesitation Decision making requires adequate diagnosis of the

problem, generation of solutions, and assessment ofchances of adverse outcomes

Workload distribution delegation of assigned tasksso no single individual is overloaded

Time management linked to situational awareness Conflict resolution includes listening well,

acknowledging feelings, and building respect


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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 havemore experience

Keep to an agreement and identify with a task

Be self-critical

Solve conflicts in a constructive way


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Teams Under Pressure

In stressful situations, team members often behave inmaladaptive 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 teamleader, nobody perceives themselves as accountable for the outcome, sothe tendency for risky decisions increases

Diffusion of responsibility Individuals fail to take action because they believe another individual will actor have already done so)

Lack of coordination

Be aware of these destructive patterns and fight them whenyou see them occurring


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Summary

Communication is a key aspect of acute medical care in anenvironment 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 goodteam communication


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And Finally

Dont overestimate your abilities! Just as calling for help is useful ina medical crisis, turning to others can assist in conflict resolution.


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References

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

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

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

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

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

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

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