Upload
stanford-anesthesia
View
221
Download
0
Embed Size (px)
Citation preview
8/2/2019 Communication and Conflict Resolution in the or-Revised
1/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
2/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
3/26
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)
8/2/2019 Communication and Conflict Resolution in the or-Revised
4/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
5/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
6/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
7/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
8/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
9/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
10/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
11/26
Aggressive Behavior
8/2/2019 Communication and Conflict Resolution in the or-Revised
12/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
13/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
14/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
15/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
16/26
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.
8/2/2019 Communication and Conflict Resolution in the or-Revised
17/26
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)
8/2/2019 Communication and Conflict Resolution in the or-Revised
18/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
19/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
20/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
21/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
22/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
23/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
24/26
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
8/2/2019 Communication and Conflict Resolution in the or-Revised
25/26
And Finally
Dont overestimate your abilities! Just as calling for help is useful ina medical crisis, turning to others can assist in conflict resolution.
8/2/2019 Communication and Conflict Resolution in the or-Revised
26/26
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.