Communication Dynamics in the OR: Insights for Surgeon, Nurse & Administrative Leaders By Beth Boynton, RN, MS As a nurse consultant specializing in communication and collaboration among healthcare professionals, I interface with nurses of many specialties including those who practice in the OR. Teaching "soft" skills such as giving and receiving feedback to Peri-Op professionals offers fascinating learning opportunities for me. The OR is such a high paced, high tech, high stakes work environment and not always conducive to touchy feely stuff like "I"-statements and respectful listening. On the other hand, sentinel event statistics from the Joint Commission regarding surgically related problems along with the growing awareness in all healthcare circles that effective communication is critical in preventing errors offer compelling reasons to develop the skills. Self-reflection, ownership, and respectful communication are examples of 'soft' skills that are extremely hard to develop and practice. Yet, the surgeon or nurse manager who can teach the right way of doing something without humiliating a team member will show everyone that respect is guaranteed, skills and knowledge are required to work in the OR, and passive aggressive behavior will not rewarded with alignment. Last year in preparing an interactive workshop called Improved Quality of the OR Patients' Care Through Effective Communication and Assertiveness for a chapter of AORN. I asked their educational committee to share their most common communication challenges so that we could make our time as meaningful as possible. They replied with the following four scenarios: 1. Your team mate purposefully holding back information about a surgery to make you look bad in front of the surgeon. 2. Surgeon stating he/she wants someone in the OR that 'knows what they are doing'. 3. Purposeful negative discussion about you in the operating room by other team members without including you in the conversation. 4. Surgeon compromises patient safety either by surgical technique, not wanting to wait for "Time-Out", or not wanting to wait for 'counts' at the end of the procedure (especially when counts are incorrect), and ignores or becomes angry when you request she/he consider the information presented. These scenarios reveal layers of interwoven relationship patterns that are fraught with horizontal and vertical violence. Add to that, more innocent unawarenesses about individual behaviors and their impact on others along with lack of skills in self-reflection and expression and the complexity of interactions and ramifications begins to emerge. Team members vying for approval and leaders who are somehow gratified by giving or withholding approval are participating in relationship patterns that contribute to adverse events. Withholding information, setting up a colleague to work in a position without appropriate training and experience, or using humiliating language and tone are not in the patient's best interests. As human beings, I believe we all want and deserve to feel respected and have a sense of power. Yet in our culture some members and professions are valued more than others. This imbalance chips away at everyone's self esteem and contributes to complex feelings and behaviors involving frustration and resentment. In addition, relentless stress, gender, ego and self-esteem factors help set the stage for such aggressive, passive aggressive or passive ways of obtaining power. I hate to think of my colleagues in the nursing and medical professions behaving in these ways, yet also feel a little defensive. I know how I feel along the course of a highly stressed shift as a Per Diem RN on an Alzheimer's unit. I can practically watch my 'best self' disintegrate with relentless alarms, interruptions, dementia behaviors, changing priorities, and chronic understaffing. I'm pretty good at owning and apologizing for any irritability, but that may be after a sarcastic or short-tempered remark. Despite the fact that I can empathize with poor conduct, I passionately believe that individuals and organizations can do better. Even under pressure, a mistake requiring a immediate substitution of staff can be handled with respect. A statement such as; "I need trained OR assistance, now!" is quite different from, "Get someone in here who knows what they are doing! They both get the same problem addressed, but first statement brings up an organizational responsibility re: training, while the second is more blaming of the individual. Making sure that the situation is followed up as soon as possible after surgery by debriefing with surgeon, nurse manager and staff will identify training problems, seek solutions and practice giving and receiving constructive feedback. Whenever I hear about situations like these, I look for individual and organizational factors. Solutions that consider both less blaming and more likely to lead to long-term, meaningful change. Administrative leaders have a responsibility to advocate for resources required to focus on communication training, opportunities to practice skills and recognizing learning curves. Individuals have a responsibility to seek help, acknowledge limitations and develop their skills. Not everyone is cut out to work in the OR, (or on an Alzheimer's Unit) and career coaching and/or discipline may also be necessary. I don't know exactly what respectful communication looks like in the operating room, but I suspect there is a unique opportunity for peri-op professionals to define, develop and practice it. Facilitated discussion among OR staff about the following questions could be a rich process: What does respectful communication look like in the OR? What makes it challenging or different here? What do we need to do to practice it? Positive outcomes like creating new norms, safer surgery, increased collaboration, personal and professional growth and improved morale are all possible! I love engaging healthcare professionals in respectful conversations about tough issues. There is so much co-creative potential to tap into! Let me know your thoughts! Email Beth

Communication Dynamics

in the OR: Insights for Surgeon, Nurse & Administrative Leaders

By Beth Boynton, RN, MS

As a nurse consultant specializing in communication and collaboration among healthcare professionals, I interface with nurses of many specialties including those who practice in the OR. Teaching "soft" skills such as giving and receiving feedback to Peri-Op professionals offers fascinating learning opportunities for me.

The OR is such a high paced, high tech, high stakes work environment and not always conducive to touchy feely stuff like "I"-statements and respectful listening. On the other hand, sentinel event statistics from the Joint Commission regarding surgically related problems along with the growing awareness in all healthcare circles that effective communication is critical in preventing errors offer compelling reasons to develop the skills.

Self-reflection, ownership, and respectful communication are examples of 'soft' skills that are extremely hard to develop and practice. Yet, the surgeon or nurse manager who can teach the right way of doing something without humiliating a team member will show everyone that respect is guaranteed, skills and knowledge are required to work in the OR, and passive aggressive behavior will not rewarded with alignment.

Last year in preparing an interactive workshop called Improved Quality of the OR Patients' Care Through Effective Communication and Assertiveness for a chapter of AORN. I asked their educational committee to share their most common communication challenges so that we could make our time as meaningful as possible. They replied with the following four scenarios:

1. Your team mate purposefully holding back information about a surgery to make you look bad in front of the surgeon.

2. Surgeon stating he/she wants someone in the OR that 'knows what they are doing'.

3. Purposeful negative discussion about you in the operating room by other team members without including you in the conversation.

4. Surgeon compromises patient safety either by surgical technique, not wanting to wait for "Time-Out", or not wanting to wait for 'counts' at the end of the procedure (especially when counts are incorrect), and ignores or becomes angry when you request she/he consider the information presented.

These scenarios reveal layers of interwoven relationship patterns that are fraught with horizontal and vertical violence. Add to that, more innocent unawarenesses about individual behaviors and their impact on others along with lack of skills in self-reflection and expression and the complexity of interactions and ramifications begins to emerge.

Team members vying for approval and leaders who are somehow gratified by giving or withholding approval are participating in relationship patterns that contribute to adverse events. Withholding information, setting up a colleague to work in a position without appropriate training and experience, or using humiliating language and tone are not in the patient's best interests.

As human beings, I believe we all want and deserve to feel respected and have a sense of power. Yet in our culture some members and professions are valued more than others. This imbalance chips away at everyone's self esteem and contributes to complex feelings and behaviors involving frustration and resentment.

In addition, relentless stress, gender, ego and self-esteem factors help set the stage for such aggressive, passive aggressive or passive ways of obtaining power.

I hate to think of my colleagues in the nursing and medical professions behaving in these ways, yet also feel a little defensive. I know how I feel along the course of a highly stressed shift as a Per Diem RN on an Alzheimer's unit. I can practically watch my 'best self' disintegrate with relentless alarms, interruptions, dementia behaviors, changing priorities, and chronic understaffing. I'm pretty good at owning and apologizing for any irritability, but that may be after a sarcastic or short-tempered remark. Despite the fact that I can empathize with poor conduct, I passionately believe that individuals and organizations can do better.

Even under pressure, a mistake requiring a immediate substitution of staff can be handled with respect. A statement such as; "I need trained OR assistance, now!" is quite different from, "Get someone in here who knows what they are doing! They both get the same problem addressed, but first statement brings up an organizational responsibility re: training, while the second is more blaming of the individual. Making sure that the situation is followed up as soon as possible after surgery by debriefing with surgeon, nurse manager and staff will identify training problems, seek solutions and practice giving and receiving constructive feedback.

Whenever I hear about situations like these, I look for individual and organizational factors. Solutions that consider both less blaming and more likely to lead to long-term, meaningful change. Administrative leaders have a responsibility to advocate for resources required to focus on communication training, opportunities to practice skills and recognizing learning curves. Individuals have a responsibility to seek help, acknowledge limitations and develop their skills. Not everyone is cut out to work in the OR, (or on an Alzheimer's Unit) and career coaching and/or discipline may also be necessary.

I don't know exactly what respectful communication looks like in the operating room, but I suspect there is a unique opportunity for peri-op professionals to define, develop and practice it. Facilitated discussion among OR staff about the following questions could be a rich process:

•What does respectful communication look like in the OR?
•What makes it challenging or different here?
•What do we need to do to practice it?

Positive outcomes like creating new norms, safer surgery, increased collaboration, personal and professional growth and improved morale are all possible!

I love engaging healthcare professionals in respectful conversations about tough issues. There is so much co-creative potential to tap into! Let me know your thoughts! Email Beth