Communication and Conflict Resolution in the OR

JENNIFER BASARAB-TUNG ABDOMINAL SURGERY ROTATION

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 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 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 interaction Changing anesthesiologist assignment just before the

beginning of a case Double-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 aggression

In 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, Avoid distracting activities such

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

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

Wait for the heightened emotion to recede before responding

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 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

Four Aspects of a Message

Helpful 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 its not always what we say thats 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 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 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 youre saying we havent assessed for hyperkalemia and should check an ABG potassium now) Be supportive of the person you are talking with

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 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 collaboration

The 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 awareness Conflict 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
Individuals fail to take action because they believe another individual will act or have already done so)

Diffusion of responsibility

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
Dont 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.