A view from the coffee room… on communication in the OR

I maintain a shortlist of stupid or dare I say idiotic statements given by hospitals top administration to the newspapers. A decade ago, we were in a similar situation as today: a lack of nurses. The solution to this shortage was to bring in nurses from other countries. So far this sounds great, but there is more to this. In the newspapers I learned that the nurses were to be placed in the OR. Again fine, we need to do operations and operate more. The next sentence blew my mind: these nurses were placed in the OR since they did not have to learn Finnish, because no one talks in the OR.

So, basically everyone in the OR, surgeons, anesthetists, nurses and orderlies, work in total silence; maybe listen to radio, but no talking. We don't say a word. Maybe we communicate with hand gestures or perform pantomime. To me, this shows that the hospital administration does not understand what kind of work is done in the OR and especially how the work is actually done. Communication is of the utmost importance in the OR. One of the first things I learned in OR about communication, was that anyone can and should speak out if they notice shortcomings in sterility. This is really, really important.

As the old saying goes, an anaestheist’s emergency is in seconds, and a surgeon’s in minutes. These are such short times that performing a pantomime or making hand signals can result in the patient's death. Just try to wave your hands while you try to ligate a heavily bleeding vein; it is difficult. Not to mention that, to get to the ligation part, you must have signaled that you want a suture, with the needle on it (or not), describe the suture thickness 1 , multi- or monofilament and finally absorbable or not-absorbable. Not. Gonna. Happen.

Phew, now that I got this out of my system, we can continue to examine communication in the OR. It seems that most of the articles on communication are concerned with when the communication fails miserably 2-5. Why so negative? Let's take a fresh view from ethologists, i.e. people who study animal behaviour, as we are animals and not plants.

First, I learned that mixed-gender teamwork, that is, individuals of both, nowadays it should be all genders, working together under stressful situations, is rare during mankind’s history6. Another interesting point ethologists noticed was that our teams change constantly6. Thus, we lack thebenefits of established and long-term role divisions6. Here may lie the root cause to communication challenges in OR6.

Most of the OR communication is about personal lives, current events, and popular culture, rather than case-related talk or information 6, very accurate and true! Luckily, most of the communication in the OR was interpreted as co-operative, 59% 6. Things get interesting when we look at the conflicts – consultant surgeons start the majority of conflicts (67.4%). The recipients of this conflict talk – let´s call it honestly, rage - are usually a circulating nurse (26.3%) and/or surgical resident (20.6%). It must be noted – and I think this is important – age or gender of the attending surgeon did not have statistically significant effect in co-operation or conflict communication 6. We all start equally in co-operative conversation or battles. We all should take a good, long look in the mirror.

Ethologists from Denmark observed four different kinds of interdisciplinary OR communications at a micro level using content analysis: proactive and intuitive communication, silent and ordinary communication, inattentive and ambiguous communication, and contradictory and highly dynamic communication7. I found this stratification fascinating, and it actually verbalized my own observations, on the effect of complexity and duration of the operation to communication. It made me think.

When we think of OR communication, I am pretty sure that we all think about communication during the operation itself. It is of merit to the Danish ethologist that they bring to our attention that inattentive and ambiguous communication during surgery may start way earlier7. It starts with the surgeon not answering the phone when the OR nurse calls to get more or detailed information about the operation, such as the patient's position, what instruments are needed, and whether antibiotics are needed. If this pre-operative communication fails, it affects the intra-operative communication7. In this situation per operative communication was guided by functional goals and not by shared goals7. Well, if goals are not shared, then it is not teamwork. So, answer that bleeping phone when OR calls!