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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns

Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre Terhi Korkiakangas a,b,*, Sharon-Marie Weldon a, Jeff Bezemer b, Roger Kneebone a a b

Department of Surgery and Cancer, Imperial College London, UK Department of Culture, Communication and Media, Institute of Education, UK

A R T I C L E I N F O

A B S T R A C T

Article history: Received 11 April 2013 Received in revised form 8 January 2014 Accepted 10 January 2014

Background: One of the most central collaborative tasks during surgical operations is the passing of objects, including instruments. Little is known about how nurses and surgeons achieve this. The aim of the present study was to explore what factors affect this routinelike task, resulting in fast or slow transfer of objects. Methods: A qualitative video study, informed by an observational ethnographic approach, was conducted in a major teaching hospital in the UK. A total of 20 general surgical operations were observed. In total, approximately 68 h of video data have been reviewed. A subsample of 225 min has been analysed in detail using interactional video-analysis developed within the social sciences. Results: Two factors affecting object transfer were observed: (1) relative instrument trolley position and (2) alignment. The scrub nurse’s instrument trolley position (close to vs. further back from the surgeon) and alignment (gaze direction) impacts on the communication with the surgeon, and consequently, on the speed of object transfer. When the scrub nurse was standing close to the surgeon, and ‘‘converged’’ to follow the surgeon’s movements, the transfer occurred more seamlessly and faster (1.0 s). Conclusions: The smoothness of object transfer can be improved by adjusting the scrub nurse’s instrument trolley position, enabling a better monitoring of surgeon’s bodily conduct and affording early orientation (awareness) to an upcoming request (changing situation). Object transfer is facilitated by the surgeon’s embodied practices, which can elicit the nurse’s attention to the request and, as a response, maximise a faster object transfer. A simple intervention to highlight the significance of these factors could improve communication in the operating theatre. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: Scrub nurse Surgeon Instrument trolley Body movement Communication Situation awareness

What is already known about the topic?

* Corresponding author at: Institute of Education (University of London), Department of Culture Communication and Media, London Knowledge Lab, 23-29 Emerald Street, London, WC1N 3QS, UK. Tel.: +44 0207 763 2179. E-mail address: [email protected] (T. Korkiakangas).

 Communication, anticipation and other non-technical skills play a crucial role in situation awareness, and link to responsiveness in changing situations.  Scrub nurses’ vigilance towards the stages of surgical operations and their ability to anticipate a surgeon’s

0020-7489/$ – see front matter ß 2014 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2014.01.007

Please cite this article in press as: Korkiakangas, T., et al., Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/ j.ijnurstu.2014.01.007

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need for instruments and objects can impact on the flow of operations. What this paper adds  The paper examines actual, video-recorded interactions between scrub nurses and surgeons during surgical operations.  The paper identifies the interactional factors affecting object transfer, including instrument trolley positioning and visual orientation to surgeons’ movements, as important areas for theatre nurses’ training.  The paper shows that degree of situation awareness is visible in the bodily conduct of nurses and surgeons, and can be affected by the relative positioning of the operating theatre professionals. 1. Introduction Health care professionals, such as surgeons and nurses, work in interprofessional teams. This seemingly obvious fact has crucial importance to patient safety (Kneebone and Fry, 2011), as adverse incidents in surgical operations are often the result of breakdowns in team communication (Aggarwal et al., 2004; Lingard et al., 2004). Research on interprofessional communication in the operating theatre has drawn on different methodologies, including observational rating scales and interviews. Communication problems are frequently reported. According to Lingard et al. (2004), as much as 31% of all communications in the operating theatre could be categorised as failing some way. For example, information provided to colleagues can be inaccurate, delivered too late, or it fails to reach the individuals who need it, leaving issues unresolved until they become critical. In a recent systematic review, Weldon et al. (2013) found that there are not many video-based studies that elaborate on the actual, real-time communication behaviours in the operating theatre. Communication breakdowns can have many consequences. They can cause delays that compromise the quality of patient care and the management of subsequent operations. As a result, delays in operations can incur substantial costs to hospitals (Wong et al., 2010). When an operation is in progress, surgeons and scrub nurses routinely exchange instruments, and this requires communication and alertness from both parties. Dropping instruments alone has been shown to extend operating time on average by 7.6 min (Khan et al., 2008). However, studies have not elaborated how non-vocal behaviours, such as eye-gaze and hand movements, might contribute to such incidents. Task-related communication is closely linked to situation awareness. This concept refers to a dynamic process of acquiring information from the immediate environment and responding accordingly to changing situations. There is no single definition of situation awareness but its understanding can be roughly divided into two concerns: the view of awareness primarily as a psychological, cognitive phenomenon (e.g., Endsley, 1995); or as a distributed awareness, involving interactions between people, artefacts, and the environment (Stanton et al.,

2006). The widely cited model by Endsley involves three levels: perception of environmental elements in a time and space, understanding their meaning, and using this information to predict events that are likely to happen. Anticipation is an important part of situation awareness, enabling an individual to respond rapidly to changing situations, and potentially preventing adverse incidents from occurring. Interpersonal communication and interaction with artefacts have also been suggested to impact the awareness of what is happening in one’s surroundings (Endsley and Jones, 2001). However, some researchers have called for a broader attention to these factors, so as to move the focus from individual cognition to collaboration (Salmon et al., 2008). Coordination of activities is important for the efficient delivery of surgical operations. Therefore, understanding of situation awareness from the angle of communication becomes relevant. Bromiley (2008) notes how a lack of situation awareness and breakdowns in communication count as human factors that are present in fatal incidents in healthcare, but also in 75% of aviation accidents. A lapse in situation awareness can occur when attention is ‘‘fixated’’ and a professional fails to re-orient and to change a course of action (Bromiley, 2008). As such, situation awareness has particular relevance for scrub nurses. These nurses are ‘‘scrubbed up’’ to work within the sterile zone, and they continuously guard, count, and handle sterile instruments and items, such as swabs and syringes, on the instrument trolley. Their main task is to pass these items to the surgeon, ideally at the precise time of need, so as to avoid any delays in the stages of an operation. Instrument exchange can be cognitively demanding, as the task requires constant vigilance and technical knowledge of the actual operation. Scrub nurses have to remain situationally aware to select the right instrument at the right time (Mitchell and Flin, 2008), and to ‘‘both think and remain ‘ahead’ of the surgeon’’ (Mitchell et al., 2011, p. 822). Situation awareness has been suggested to be one of the most important non-technical skills that scrub nurses have to master in the operating theatre (Mitchell and Flin, 2008). While such skills have been researched and assessed among surgeons (e.g. Non-Technical Skills for Surgeons [NOTSS], Yule et al., 2008), less is known about how nurses’ non-technical skills relate to situation awareness. Where nurses’ situation awareness has been examined more generally, these studies have tended to draw on cognitive assessments (Wright, 2009) and interviews (Mitchell et al., 2011). While these are important methods, they do not always reveal the details of actual interactions and how people display awareness of the events around them: this is often beyond their awareness. Hence, operating theatre nurses often talk about a ‘‘tacit understanding’’ between colleagues (Gillespie et al., 2010, p. 736). To address the relative lack of research on theatre nurses’ non-technical skills, The Scrub Practitioners’ List of Intraoperative Non-Technical Skills (SPLINTS) behavioural rating scale (Mitchell et al., 2012) has been recently developed. It focuses on the assessment of non-technical skills, situation awareness, communication and teamwork,

Please cite this article in press as: Korkiakangas, T., et al., Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/ j.ijnurstu.2014.01.007

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and task management among scrub nurses. For example, the core category of situation awareness includes elements of ‘‘gathering information’’, ‘‘recognising and understanding information’’ and ‘‘anticipating’’, while two important elements of communication and teamwork are ‘‘exchanging information’’ and ‘‘coordinating with others’’. Mitchell et al. showed that scrub practitioners have found the rating scale useful in assessing simulated scenarios representing good and bad practice in these core non-technical areas. Some studies involving anaesthetists, surgeons and perfusionists (Fioratou et al., 2010; Hazlehurst et al., 2007; Parush et al., 2011) have considered situation awareness as a process where verbal communication and interaction with objects are paramount. Hazlehurst et al. show that vocal practices, such as requests and confirmations serve as important resources: A surgeon might ask a perfusionist to adjust the flow of fluids, and the perfusionist vocally confirms this after the adjustment has been done. The spoken clarification informs the surgeon that a transition to a new state has begun, establishing mutual understanding of the situation. Such research suggests that situation awareness can become ‘‘visible’’ through the study of actual interactions. 2. Researching communication through video research Video offers an innovative way to examine communication that underpins situation awareness in a greater detail that has been done before. A previous study in an organisational work environment in an organisational work environment has shown that activities of one colleague can unobtrusively encourage others to ‘‘notice’’ critical elements in the environment (Heath et al., 2002). In such cases, awareness is built in and through interactions with others. Through video, real-time activities can be accessed repeatedly, so that their detailed scrutiny becomes possible. Communication through posture shifts, arm movements, gaze behaviours, and the like can be analysed on a second-by-second basis. Such detail would be difficult to recollect in interviews or to articulate in retrospective accounts when ‘‘the moment’’ has passed. In a recent ethnographic study that employed video recordings as part of the observation of ward nurses’ handover practices, Liu et al. (2012) described how the nurses routinely communicated through non-vocal means, such as by exchange of glances or gestures. Other studies (drawing on conversation analytic frameworks) in the operating theatre, or specifically in anaesthesia (Hindmarsh and Pilnick, 2007), have shown that bodily conduct is essential for effective collaboration and relate closely to the concept of awareness. Only a few studies have focused specifically on scrub nurses. In an eye-tracking study of visual attention, Koh et al. (2011) reported that scrub nurses frequently used distinctly different visual sources of information for different tasks during an operation. The most frequently gazed areas were the operating field, patient’s lower body, Mayo stand (a sterile tray on a stand for instruments that may be immediately needed by the surgeon; the tray is often positioned over the patient’s lower body) and the main instrument trolley. The nurses’ attentiveness

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towards the operating field and the surgeon’s manual actions indicate that a gaze direction to these areas might be central for anticipating instrument needs (Koh et al., 2011). This suggests that situation awareness and anticipation are processes that are visible and externalised in bodily conduct, as when one attends to a colleague’s manual actions. Through a close examination of video-recorded instrument transfer episodes, Sanchez Svensson et al. (2007a) noted also that the arrangement of surgical instruments on the instrument trolley embodies nurses’ awareness of surgeons’ needs during an operation. Furthermore, these authors demonstrated that, [a]wareness does not simply rely on participants possessing the same information or knowledge about a particular activity but more on how they are able to contribute actively to the contingent organisation of awareness and interaction – in this case, the ways in which the participants in and through the grasping, handling, organisation and use of instruments can orientate prospectively to the upcoming actions and concerns of others. (p. 43) Others have elaborated how the seemingly unproblematic instrument passing does not simply rest on the vocal requests (e.g., ‘‘Scissors, please’’) uttered by surgeons, but also on the simultaneous body movement and gaze practices that project the upcoming request to a nurse (Bezemer et al., 2011; also Koschmann et al., 2011). Bezemer et al. have shown how a surgeon can simultaneously engage in two different activities, knot tying and instrument exchange: scissors are requested exactly when needed through an arm movement towards the nurse. Likewise in other contexts, such as medical consultations (Heath, 1986), parties’ orientation to body movements have been shown to push mutual engagement in motion. Less is known about the ways in which scrub nurses, in particular, juggle different activities during operations, and how they display their awareness of the surgeon’s needs through their bodies. The focus on subtleties of behaviour offers practical value in improving communication, so that crucial tasks can be accomplished effectively. The present paper aims to address the gap of detailed video-based studies of situation awareness in the operating theatre. The analysis demonstrates how a scrub nurse and a surgeon build mutual awareness interactionally when exchanging syringes, scalpels, and swabs. The study elaborates on the link between body movement and situation awareness, and considers whether the relative proximity of the instrument trolley, the scrub nurse and the surgeon impacts on communication and the speed of object transfers. 3. Method 3.1. Methodological framework The current study is part of a video ethnographic research project examining communication in the operating theatre. The project was centrally concerned with how operating theatre team members communicate using

Please cite this article in press as: Korkiakangas, T., et al., Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/ j.ijnurstu.2014.01.007

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different modes of communication (speech, gaze, movement, gesture, and handling of objects). Video ethnography was used to capture teamwork and communication events as they happened inside the operating theatre, and to record fleeting moments and detailed (vocal and nonvocal) aspects of communication that would be missed or forgotten otherwise. Communication was analysed using video analysis (Heath et al., 2010) that draws on the framework of conversation analysis (CA) (Schegloff, 2007). This framework enabled the examination of why particular communication events happened and how they were organised. Video analysis proceeds through a detailed transcription of the actions that people perform – that is, it systematically describes and visualises a series of actions. People perform these actions through different forms of bodily conduct, such as speech, gesture, movement, and gaze. Interactional transcription and analysis renders visible how these actions are ordered as sequences: for instance, how an instrument request is made and followed by the provision of the instrument. Thus rather than considering the actions of the clinicians in isolation, it will be considered how each participant’s conduct emerges in relation to the actions of others. Such detailed description can make visible exactly how particular joint tasks, such as object exchanges, are achieved and sometimes not achieved. This framework was selected as it provides analytic tools for making situation awareness and tacit understanding visible in micro-level communication. Field notes and brief informal interviews were conducted with the participants to support and to clarify observations. Two authors (TK [social interaction researcher with expertise in video analysis] and SMW [research nurse with background in operating theatre nursing]) were centrally involved in the data collection and analysis. 3.2. Data source Operating theatre professionals were recruited from a UK health institution as part of a project funded by the Economic and Social Research Council (ESRC). Specific surgeons who were previously known to some members of the research team were first approached about participation in the observational study. Having gained these surgeons’ consent to observe their operations, two researchers (TK and SMW) from the team approached the theatre manager and gained her consent to attend the theatres and to observe (and eventually to film) operations. Theatre nurses, anaesthetists and operating department practitioners (ODPs) were conveniently recruited. They were approached on the morning of a set of operations that the researchers attended to observe (consent was often gained continually due to a frequent rotation of staff). The researchers spent a month observing operations during which they familiarised themselves with the theatre staff. The surgeons, nurses, ODPs, and anaesthetists were then separately consented to being filmed after the researchers had gradually introduced their wish to collect video data of teamwork in the operating theatres.

Table 1 Collected cases and types of operation observed. Type of operation Laparoscopic staging Oesophogectomy Laparoscopic sigmoidectomy Laparscopic fundoplication Laparoscopic gastric bypass Laparoscopic sleeve gastrectomy Laparoscopic gastric band Laparoscopic internal hernia repair Laparoscopic cholecystectomy Staging laparotomy Open hernia repair Total

Cases 4 1 1 1 1 3 2 2 2 2 1 20

The project was granted the NHS Research Ethics Committee approval, as well as a Site Specific Assessment (SSA) approval at the participating NHS Trust. The study was conducted in accordance with the recommendations for physicians involved in research on human subjects adopted by the 18th World Medical Assembly, Helsinki 1964 and later revisions. Video recordings of 20 operations were conducted over the period of three months in two different theatres, representing a mixture of open and laparoscopic procedures (see Table 1). In total, the data corpus involves approximately 68 h of video recordings of three consultant surgeons (attending surgeons), three registrar surgeons (resident surgeons), five scrub nurses, six circulating nurses, three consultant anaesthetists and three ODPs. In the current study, a subsample of two cases has been considered to examine instrument transfer episodes. This subsample includes two laparoscopic operations, with duration of 118 min (Case A; gastric banding) and 107 min (Case B; internal hernia repair), involving one consultant surgeon who was assisted by a different scrub nurse in both cases. The illustrative examples presented in this paper were taken from this subsample. The two cases were selected for analysis following an initial stage of unmotivated looking (see Psathas, 1995) of the data. During this stage, the entire video corpus was viewed ‘‘openly’’. That is, interactionally relevant phenomena were allowed to emerge from the data, as opposed to having preconceptions or hypotheses to guide the observations. It was noted that, in Case A and Case B, the instrument exchanges occurred differently, insofar as the former case was characterised as involving ‘‘smoother’’ exchanges than the latter case. It was decided to examine these cases more closely in order to understand the factors that appeared to impact this smoothness. 3.3. Data collection The two researchers (TK and SMW), who jointly observed operations, recorded data with two tripodmounted wide-angle HD Sony camcorders. The cameras were positioned so as to capture different viewpoints of the theatre. Two inconspicuous RevoLabs xTab wireless microphones were used for audio recording, worn by the consultant and the scrub nurses under their sterile gowns.

Please cite this article in press as: Korkiakangas, T., et al., Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/ j.ijnurstu.2014.01.007

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Field notes were continually recorded during data collection and often included events not captured by the cameras. Participant interviews were conducted when the operating theatre members had a free moment and these were recorded with a Dictaphone. 3.4. Video analysis The analysis proceeded through a careful review of the video recordings. During the stage of unmotivated looking, recurring interactional phenomena were detected, which were subsequently subjected to in-depth, interactional video analysis (see Section 3.5). Two authors (TK and SMW) re-inspected the entire video corpus, creating a detailed log of every form of interactional event (e.g., request, utterance, question, repetition, response; whether response was produced vocally or non-vocally; associated bodily conduct/position) from each team member, and linking these events with a unique time code identifier (using InqScribe software). The initial observations were then closely examined with the logs, and selected examples were transcribed to enable a sequential analysis of the emerging actions (see below). It was observed that object exchange was a predominant feature of the scrub nurse–surgeon interactions, and that it involved both vocal and non-vocal communication. Transferring objects between colleagues is clearly a routine task, and the observations suggested that these exchanges often occurred in a smooth and timely manner at the research site. However, they were occasionally delayed or did not occur at all, resulting in a ‘‘no-exchange’’ whereby surgeons reached to the object themselves. It was decided to examine this variation in the apparent smoothness of object transfer in more detail in a subsample of two cases (see ‘‘Data Source’’ for information on case selection). By focusing on the selected case examples, which involved re-playing of the selected video clips of object exchanges 25 times or more (often in slow motion; zooming in on the professionals’ face and hand areas), drafting of transcripts (see below) of the (selected) short item passing episodes, and timing of lapses between requests and responses, it was possible to examine the fine detail of surgeon and nurses’ conduct that seemed to explain some of the variation. In this paper, the transcripts has been synthesised into detailed descriptions of the passing episodes, and still images have been used to illustrate the key analytical moments. Object passings were described quantitatively in terms of their speed and qualitatively in terms of the interaction involved in the passings. The analysis was refined by the team of authors, who together reviewed the examples extracted from the subsample. The findings were further explored in a roundtable meeting involving some of the nurses and surgeons who were filmed as part of the research. 3.5. Defining analytic focus The review of the video data rendered visible two basic interactional arrangements that scrub nurses adopted during surgical operations: alignment with the surgeon and the operating field and alignment with other people,

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objects and actions. These alignments were related to the nurses’ gaze activities: whether they converged to gaze at the surgeon and the operating field, or whether they converged to attend other concerns, such as the instrument trolley or another nurse. A closer review suggested an association between these alignments and the relative position of the instrument trolley during an operation (see Table 2). Interactions where the scrub nurse either converged or diverged with the operating surgeon, moments before an object exchange occurred, were then subjected to a more detailed video analysis in a subsample. The focus of the analysis was on the impact of these arrangements on the item passing episodes, namely whether the passings occurred ‘smoothly’ or less ‘smoothly’, and what in these arrangements appeared to account for the variation. The principle of sequential organisation of interactions, derived from the framework of conversation analysis (Schegloff, 2007), was used to inform the observations: when a request for an instrument or item was issued, a response was expected, and any delay in responsiveness could be some way problematic. Therefore the analysis was conducted to delineate the nurses’ behaviours during the lapse between a request and a response (i.e., item passing) and just before a request had been issued, in order to examine the factors that seemed to impact on their fast or slow responsiveness to the requests. Furthermore, the ways in which surgeons constructed their requests were also considered as a factor that impacted on the nurses’ responsiveness to pass the requested items. The quantitative rating was used to calculate the average speed of passings per case. The lapse of approximately 1 s was used as an indicative measure, based on the principle of ‘‘a standard maximum silence’’ of approximately 1 s in conversations (Jefferson, 1989). This principle, drawn from conversation analytic research, relates to an observation that a delay in responding to an initiating action is often taken to indicate some kind of interactional trouble (for example, problems of hearing or understanding with respect to the initiating action; disagreements with the prior turn, see Pomerantz, 1984). While previously used as a numerical indicator of silences in ordinary conversations, it was noted that the lapse of approximately 1 s was also applicable when distinguishing between fast and slow non-vocal responses (i.e., the onset of item passings) in the present study. Thus the speed of passings was measured in terms of the time lapse between the surgeon’s request for a passing and the scrub nurse’s response to that request. Passings taking less than a second were classified as ‘fast’, and passings taking a second or more were classified as ‘slow.’ The qualitative rating was used to map the different ways in which passings were achieved. Interaction was defined as the concerted actions of participants involved in passing of items. Interactions were described in terms of (1) the surgeon’s signalling of a request for a passing (i.e. the vocal and/or non-vocal means by which the request is articulated); (2) the scrub nurse’s focus of attention at the time of the signalling (i.e. the physical orientation of the scrub nurse); and (3) the scrub nurse’s response to the request for assistance. The contexts of item passings were

Please cite this article in press as: Korkiakangas, T., et al., Nurse–surgeon object transfer: Video analysis of communication and situation awareness in the operating theatre. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/ j.ijnurstu.2014.01.007

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Table 2 The indicative position and alignment of the scrub nurses during operations. Relative position

Alignment

Instrument trolley positioned close to surgeon and operating field.

Scrub nurse follows the gaze and movements of surgeon.

Surgeon and registrar are standing at the opposing sides of the operating field.

Instrument trolley positioned behind or far away from surgeon and operating field.

Scrub nurse’s gaze is directed away from the operating field and surgeon (e.g., directed at instrument trolley).

Surgeon and registrar are standing side-by-side on the same side of the operating field.

also described, namely in terms of participants (scrub nurse, surgeons) and objects involved (e.g. syringe, instrument, swab) and their spatial arrangement (i.e. layout). Using this framework a detailed analysis of video recorded object passings was undertaken. Photo stills illustrate the key moments and provide access to the activities discussed in the analysis. 4. Findings 4.1. Description of two cases Thesubsampleof two surgical cases(hereafter,Case A and Case B) represents two different contexts for the item exchange. While they involve the same consultant surgeon, the nurses, including the scrub nurse, as well as the assistant surgeons (registrars) are different. In both cases, the scrub nurses had placed their instrument trolleys in different positions. The trolley position was not pre-arranged by the researchers and it was not discussed with the nurses beforehand (rather, the trolley position was the scrub nurses’ own decision). In Case A, the trolley was located in front of the scrub nurse and close to the surgeon, so that the scrub nurse and surgeon were standing side by side (see Fig. 1). In Case B, the trolley was placed behind the surgeon, so that the trolley was positioned between the surgeon and scrub nurse (see Fig. 2). This was re-arranged approximately 30 min into the operation as the scrub nurse in Case B moved the instrument trolley forward and closer to the surgeon (see Fig. 3).

The trolley positioning appeared to be associated with the surgeons’ positioning during different stages of the operations. Namely, while the consultant surgeon was standing on the same side of the operating table as the scrub nurse both in Case A and Case B, in Case B the registrar was standing next to the surgeon (see Fig. 2). In Case A (Fig. 1), it was the scrub nurse who had adopted the place next to the surgeon, as the registrar was standing on the other side of the operating table. Indeed, in Case B, the scrub nurse spontaneously moved her trolley to the same position as in Case A as soon as the consultant changed his position to the other side of the operating table (see Fig. 3).

Fig. 1. Case A: trolley close to surgeon.

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Fig. 3. Case B: trolley position after change.

Fig. 2. Case B: trolley far from/behind surgeon.

4.2. Quantitative analysis

4.3. Qualitative video analysis

The results of the systematic analysis of the speed of passings in the two cases are presented in Table 3. The percentages and their confidence intervals indicate that an instrument trolley positioned close to the operating surgeon had almost a double the amount of fast responses compared to that of a further away instrument trolley. The confidence intervals between the proximity of instrument trolleys (close and far) do not overlap suggesting a true association between trolley distance and response speed. When the instrument trolley was positioned close to and adjacent with the surgeon, the percentage of fast object passings was approximately the same in Case A and Case B, 88% (116/132 = 88%) and 86% (80/93 = 86%) respectively. However, in Case B, when the instrument trolley was initially positioned far/further back from the surgeon, the percentage of slow passings was 54% (14/26 = 54%). This is approximately 4 greater than after the scrub nurse (in Case B) had repositioned herself and the instrument trolley so that they were closer to the surgeon (13/93 = 14%). This percentage (14%) of slow passings (after trolley repositioning in Case B) is very close to the percentage of slower passings in Case A, where the scrub nurse had her instrument trolley positioned close to the surgeon throughout the operation (16/132 = 12%). This strong association highlights a slower response speed with a further away instrument trolley compared to a close trolley, and their corresponding confidence intervals do not overlap.

Systematic qualitative analysis of the interactions involved in these passings is shown in Table 4. This table provides a description of four passings (two passings from each of the two cases described above), illustrating a range of different realisations of the constituent categories of the interactional framework. These four passing episodes will be considered as follows. The two passings in Case A (Passings A1 and A2) are of a dish containing a syringe or a scalpel. The two passings in Case B are of a scalpel on a dish (Passing B1) and of a swab (Passing B2), respectively. The passings in Case A are examples of ‘fast’ passings (time lapse 1.0 s). Table 4 shows that in the selected passings, the surgeon articulated a request (i.e. a request for an item or a request for the nurse to take an item back) in different ways. In one passing (B2) the request was formulated vocally only (‘‘Swab please’’). In two passings (A2 and B1) the surgeon signalled a request non-vocally only, by momentarily orienting his body towards the scrub nurse and away from the operating field. In one passing (A1) the surgeon used both vocal and non-vocal means of signalling the need for a syringe. In this passing, the surgeon started shifting his body towards the scrub nurse before he voiced the request (‘‘Local please’’). The scrub nurses’ focus of attention at the time these requests were made varied. In one passing, the scrub nurse

Table 3 The frequency of occurrence of fast and slow object passings.a Case A Trolley far

Case B Trolley close N

Fast Slow Total

N/Ab N/Ab

116 16 132

Trolley far % (95% CIs) 88 (82.5, 93.5) 12 (6.5, 17.5) 100

N 12 14 26

Trolley close % (95% CIs) 46 (26.8, 65.2) 54 (34.8, 73.2) 100

N 80 13 93

% (95% CIs) 86 (78.9, 93) 14 (6.9, 21.1) 100

a

The frequencies should be taken as indicative of direct request-response sequences in which a request was responded to either fast or slowly. The table does not include cases where the surgeon took an item from or placed an item on the Mayo stand directly and did not require the scrub nurse’s assistance. Any ‘no-exchange’ has been recorded as a slow response due to the fact that, in those cases where the surgeon himself reached for the item, the nurse still responded (i.e., by attempting to grab or to pass the item) but did so only after the surgeon’s reaching gesture and as the sought item was already in the surgeon’s hand. b The trolley was not positioned far but remained close to surgeon throughout the operation.

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Table 4 Qualitative descriptions of four object passings. Passing A1

Passing A2

Passing B1

Passing B2

Surgeon’s articulation/signal of request Scrub nurses focus of attention Scrub nurse’s response

Vocal + non-vocal Surgeon Passes requested item to surgeon

Non-vocal only Circulating nurse Takes item back from surgeon

Vocal only Writing Remains focused on writing

Time lapse (s)

0.97

0.22

Non-vocal only Trocar in hand Attempts to pass requested item to surgeon 7.0

was looking in the direction of the surgeon and the operating field (A1). In the other three passings, the scrub nurse was physically oriented to other activities (talking to a circulating nurse, preparing a trocar, writing a specimen label). The scrub nurses responded differently to the surgeon’s signals. They either responded prospectively, preparing for and initiating a passing as requested (A1 and A2), or retrospectively, only initiating a passing after repeated signalling by the surgeon (B1 and B2). The speed of the passings also varied, ranging from fast (less than a second: A1 and A2) to slow (6 s or more: B1 and B2). The table further shows that fast passings occurred after the surgeon had signalled requests vocally and nonvocally while the scrub nurse’s focus of attention was on the surgeon, but also after the surgeon had signalled the request non-vocally only while the scrub nurse was focused on a conversation with a circulating nurse. This

6.0

suggests that neither vocalisation of a request by the surgeon or physical orientation to the surgeon by the scrub nurse is a prerequisite of fast object passing. This observation will be considered shortly in more detail. Table 5 summarises the frequency of occurrence of vocal or non-vocal requests by the surgeon, and the frequency of occurrence of the scrub nurses’ fast or slow passings in response to these different types of requests. The table shows that the surgeon used more non-vocal signals when requesting for items, but only when the scrub nurse’s instrument trolley was closer to him (Case A 62.9% and Case B 67.7% [in Case B, the percentage of non-vocal signals was 42.3% when the trolley was far]). The inspection of scrub nurses’ responsiveness to vocal and non-vocal requests indicates that vocal requests are not a prerequisite for fast passings (68.1%) and that non-vocal signals also result in fast passings (91.7%) by almost a third more (Cases A and B combined). These calculations are

Table 5 Summative analysis of the surgeon’s use of vocal and non-vocal requests, and the scrub nurses’ responsiveness to these requests. Surgeon’s requests Vocal only

Case A Scrub nurse’s responses

Case B Scrub nurse’s responses

Case B Scrub nurse’s responses

With non-vocal signals

N

% (95% CIs)

N

% (95% CIs)

Trolley far Trolley close (N = 132) Fast (N = 116) Slow (N = 16)

N/Aa 49

N/Aa 37.1 (28.9, 45.3)

N/Aa 83

N/Aa 62.9 (54.7, 71.1)

40

81.6 (75, 88.2)

76

91.6 (86.9, 96.3)

9

18.4 (11.8, 25)

7

8.4 (3.7, 13.1)

Trolley far (N = 26) Fast (N = 12) Slow (N = 14)

15 5

57.7 (38.7, 76.7) 33.3 (15.2, 51.4)

11 7

42.3 (23.3, 61.3) 63.6 (45.1, 82.1)

10

66.7 (48.6, 84.8)

4

36.4 (17.9, 54.9)

Trolley close (N = 93) Fast (N = 80) Slow (N = 13)

30

32.3 (22.8, 41.8)

63

67.7 (58.2, 77.2)

19

63.3 (53.5, 73.1)

61

96.8 (93.2, 99.9)

11

36.7 (26.9, 46.5)

2

3.2 ( 0.4, 6.8)

Cases A and B’s response rate combined Fast response to vocal request (%) Slow response to vocal request (%)

2 sided p-value 68.1 (58.7, 77.5) 31.9 (22.5, 41.3)

Fast response to non-vocal signals % Slow response to non-vocal signals %

91.7 (86.1, 97.2) 8.3 (2.7, 13.9)

Nurse-surgeon object transfer: video analysis of communication and situation awareness in the operating theatre.

One of the most central collaborative tasks during surgical operations is the passing of objects, including instruments. Little is known about how nur...
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