Teams and Communication
Unlike teams in aviation, the military, and police and fire services,
the OR team is unusual in that there is an ambiguous command structure. Physicians
(surgeon and anesthesiologist) are nominally superior to nursing and technical staff,
but the physicians are coequally responsible for the patient during the immediate
perioperative period. Each physician, as well as the nurses and technicians, has
a primary territory of knowledge, skill, and responsibility, but there is considerable
overlap among them.
Strictly speaking, a team is defined as "a distinguishable set
of two or more people who interact, dynamically, inter-dependently, and adaptively
toward a common and valued goal/objective/mission, who have each been assigned specific
roles or functions to perform, and who have a limited life-span of membership."[94]
A team is distinct from a group in that a group is an ad hoc collection of individuals
without a specific mission and without specific roles.[94]
In the OR, all team members have the common goal of a good outcome for the patient.
However, there can be considerable disagreement about how to achieve this goal and
which elements of patient care have the highest priority. These differences are
probably traceable to the fact that the OR team is itself made up of several crews
(i.e., surgery, anesthesiology, nursing, perfusionist, radiology), each of which
has its own command hierarchy, its own global properties (professional standing,
culture, traditions, and history), and its own set of local goals and objectives
for management of the patient. The differences among the crews can be so striking
that some investigators refer to them as separate tribes (transcript of Conference
on Human Error in Anesthesia, Asilomar, CA, 1991).
Crew members work together to form a crew, and crews work together
to form a team. A critical component of the success of this process is the establishment
and maintenance of a shared mental model of the situation.[93]
To the degree that this can be accomplished, the different individuals will be able
to tailor their efforts toward a common goal. Experience working together as a crew
or team will improve the likelihood of generating a shared mental model.
As yet there are few data about these issues in the OR, concerning
both the interactions within the anesthesia crew and the interactions between the
anesthesia and surgical crews. A study of crew and team behaviors in ORs was carried
out in Basel, Switzerland.[32]
[279]
The authors found that "communication at the interface between anesthesia and surgical
teams was classified as unacceptable/absent in approximately 20% of the observations."
These communications were rated "within the lower half of the scale" in 70% of observations.
Cooke and Salas[324]
made some interesting statements
on teams and team knowledge ( Fig.
83-14
). In their view "team knowledge" is
Figure 83-14
Model showing the importance of proper communication.
When dealing with complex situations under time pressure, people tend to "mean"
a lot, but "say" little. It is important to let other team members know what you
think (mental model). Not everything that is said is necessarily heard by those
who should hear. This is often not the "fault" of the receiving end; acoustic hearing
and mental understanding are not the same. It is important for the sender and receiver
of a message to close the communication loop. Some tasks need time to be completed
and may fail. Let the team know.
more than the sum of individual team members' knowledge and they demonstrate the
need for new methods to elicit team knowledge (e.g., a collective holistic approach).
In team knowledge they distinguish between "team mental model" and "team situation
model." To judge team knowledge, information is also needed on the broader aspect
of "team cognition," involving team knowledge itself, team decision-making, team
situation awareness, and team perception. Figure
83-15
reflects these components of team cognition and team knowledge.[324]
Status and Hierarchy Effects
Status and hierarchy effects are important in team performance.
Especially in crisis situations, the lower-status crew member tends to defer to
the higher-status individual, even if that individual is performing poorly. In aviation,
Figure 83-15
Components of team cognition and team knowledge.
some airplane crashes have occurred in which overbearing captains were combined with
unassertive subordinates (first officer copilot and flight engineers). The team
was not able to respond effectively, even when the subordinates knew that something
was wrong.[325]
In aviation, as in academic anesthesia, training is an ongoing
activity in the domain. Although the captain is in charge of the flight, the captain
and the first officer (who is essentially in training to become a captain) traditionally
alternate the roles of "pilot flying" and "pilot not flying" on each leg of a flight.
Each of these roles is carefully defined and involves separate but interrelated
tasks (the pilot flying handles the flight controls, whereas the pilot not flying
handles radio communications and other tasks). In anesthesiology, the roles of the
trainee and the faculty member during patient care are rarely made explicit. The
trainee is often expected to do all tasks with only occasional assistance from the
supervisor (part of a training method known as cognitive scaffolding).
The exact responsibility for different tasks in a crisis is not predefined. It
is interesting that two factors frequently found to be associated with critical incidents
in anesthesia have been "teaching in progress" and "inadequate supervision."[163]
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