Failures in communication through documents and documentation across the perioperative pathway.

AIMS AND OBJECTIVES: To explore how communication failures occur in documents and documentations across the perioperative pathway in nurses' interactions with other nurses, surgeons and anaesthetists. BACKGROUND: Documents and documentation are used to communicate vital patient and procedural information among nurses, and in nurses' interactions with surgeons and anaesthetists, across the perioperative pathway. Previous research indicates that communication failure regularly occurs in the perioperative setting. DESIGN: A qualitative study was undertaken. METHODS: The study was conducted over three hospitals in Melbourne, Australia. One hundred and twenty-five healthcare professionals from the disciplines of surgery, anaesthesia and nursing participated in the study. Data collection commenced in January 2010 and concluded in October 2010. Data were generated through 350 hours of observation, two focus groups and 20 semi-structured interviews. A detailed thematic analysis was undertaken. RESULTS: Communication failure occurred owing to a reliance on documents and documentation to transfer information at patient transition points, poor quality documents and documentation, and problematic access to information. Institutional ruling practices of professional practice, efficiency and productivity, and fiscal constraint dominated the coordination of nurses', surgeons' and anaesthetists' communication through documents and documentation. These governing practices configured communication to be incongruous with reliably meeting safety and quality objectives. CONCLUSIONS: Communication failure occurred because important information was sometimes buried in documents, insufficient, inaccurate, out-of-date or not verbally reinforced. Furthermore, busy nurses were not always able to access information they required in a timely manner. Patient safety was affected, which led to delays in treatment and at times inadequate care. RELEVANCE TO CLINICAL PRACTICE: Organisational support needs to be provided to nurses, surgeons and anaesthetists so they have sufficient time to complete, locate, and read documents and documentation. Infrastructure supporting communication technologies should be implemented to enable the rapid retrieval, entry, and dispersion of information.

The 'time-out' procedure: an institutional ethnography of how it is conducted in actual clinical practice.

BACKGROUND: The time-out procedure is a critically important communication interaction for the preservation of patient safety in the surgical setting. While previous research has examined influences shaping the time-out procedure, limited information exists on how actual time-out communication is performed by multidisciplinary surgical team members in the clinical environment. METHODS: An institutional ethnographic study was undertaken. The study was conducted over three hospital sites in Melbourne, Australia. In total, 125 healthcare professionals from the disciplines of surgery, anaesthesia and nursing participated in the study. Data were generated through 350 h of observation, two focus groups and 20 semi-structured interviews. An institutional ethnographic analysis was undertaken. RESULTS: Analysis revealed healthcare professionals adapted the content, timing and number of team members involved in the time-out procedure to meet the demands of the theatre environment. Habitually, the time-out procedure was partially completed, conducted after surgery had commenced and involved only a few members of the surgical team. Communication was restricted and stifled by asynchronous workflows, time restrictions, a hierarchical culture and disinclination by surgeons and anaesthetists to volunteer information and openly communicate with each other and nurses. Healthcare professionals became normalised to performing an abbreviated time-out procedure. CONCLUSIONS: Patient safety was relegated in importance as productivity, professional and hierarchical discourses configured the communication practices of surgical team members to limit active, open and direct communication. Examining how the time-out procedure was conducted in the clinical environment enables possibilities to emerge for facilitating compliance with hospital and WHO guidelines.

Healthcare service provider perceptions of organisational communication across the perioperative pathway: a questionnaire survey.

AIMS AND OBJECTIVES: To gain understandings into service providers' perceptions of organisational communication and identify areas for improvement across the perioperative pathway. BACKGROUND: Effective communication among healthcare service providers is vital to the delivery of safe and quality patient care. Locally and internationally, research into sentinel and adverse events consistently demonstrate the perioperative environment and communication breakdown as recurring constituents in the generation of sentinel and adverse patient events. DESIGN: Prospective cross-sectional survey design. METHODS: Using a whole population sampling method all service providers from across the perioperative pathway including surgeons, nurses, anaesthetists, theatre technicians, patient service assistants and receptionists were surveyed using the International Communication Association survey. Responses were analysed using descriptive statistics, univariate analysis of variance and independent samples t-tests. RESULTS: In total, 281 service providers from the perioperative pathway of three Australian public hospitals completed the survey. Respondents were dissatisfied with communication from top management and service providers employed in an operating room or postanaesthetic care unit perceived the communication of information to be inadequate. Further, analysis by service providers' occupation revealed nurses were less satisfied with channels of information than surgeons and anaesthetists were less satisfied with the timeliness of information than nurses. CONCLUSIONS: Restricted communication flow was evident as many areas of organisational communication were reported to be insufficient for the transmission of information. This research highlights the need for improved communication flow between service providers, and between management and service providers, working across the perioperative pathway. RELEVANCE TO CLINICAL PRACTICE: Areas identified for communication improvement can be used to prevent communication failures and promote effective communication strategies such as meetings, education, providing time for open communication and developing organisational policy and procedures.

The role of documents and documentation in communication failure across the perioperative pathway. A literature review.

OBJECTIVE: Communication practices of healthcare professionals have been strongly implicated in the cascade of events that unfold into poor outcomes for surgical patients. The purpose of this paper is to explore the role of documents and documentation in communication failure among healthcare professionals across the perioperative pathway. The perioperative pathway consists of 3 interconnecting, but geographically distinct domains: preoperative, intraoperative and postoperative. DESIGN: A comprehensive search of the literature was undertaken to provide a focused analysis and appraisal of past research. DATA SOURCES: Electronic databases searched included the Cochrane Database of Systematic Reviews, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline and PsycINFO from 1990 to end February 2011. Additionally, references of retrieved articles were manually examined for papers not revealed via electronic searches. REVIEW METHODS: Content analysis was used to draw out major themes and summarise the information. RESULTS: Fifty-nine papers were selected based on their relevance to the topic. The results highlight that documentation such as surgeons' operation notes, anaesthetists' records and nurses' perioperative notes, deficient in the areas of design, quality, accuracy and function, contributed to the development of communication failure among healthcare professionals across the perioperative pathway. The consequences of communication failure attributable to documentation ranged from inefficiency, delays and increased workload, through to serious adverse patient events such as wrong site surgery. Documents that involve the coordination of verbal communication of multidisciplinary surgical teams, such as preoperative checklists, also influenced communication and surgical patient outcomes. CONCLUSIONS: Effective communication among healthcare professionals is vital to the delivery of safe patient care. Multiple documents utilised across the perioperative pathway have a critical role in the communication of information essential to the immediate and ongoing care of surgical patients. Failure in the communicative function of documents and documentation impedes the transfer of information and contributes to the cascade of events that results in compromised patient safety and potentially adverse patient outcomes.

Evidence for epistasis between SLC6A4 and a chromosome 4 gene as risk factors in major depression.

Linkage analysis on Utah pedigrees with strong family histories of major depression including only cases with the SLC6A4 HTTLPR short allele revealed a linkage peak on chromosome 4 (maximum HLOD = 3.5). This evidence suggests epistasis between SLC6A4 and an unknown gene as risk factors for major depression.

Gatekeeping practices of nurses in operating rooms.

This paper explores the gatekeeping practices used by operating room nurses to control information flow in their everyday clinical practice. In nursing, gatekeeping appears only sporadically in the literature and usually emerges as a secondary concept rather than being the primary focus of studies. As gatekeeping is a communication practice that has the potential to impact directly on patient safety, a more in-depth exploration of its pervasiveness and effect needs to be undertaken. Accordingly, in this paper we aim to provide an in-depth understanding about gatekeeping practices in operating room nursing by drawing on a 'network' model of gatekeeping to highlight the power relationships between stakeholders and how information is controlled. To illustrate our points, we provide four different examples of gatekeeping at an interpersonal level of interaction. Data are drawn from an ethnographic study in Australia that explored nurse-nurse and nurse-doctor communication at three different operating room departments. We explore the impact of gatekeeping on social and professional relationships as well as how it has practical and ethical ramifications for patient care and the organisation of clinical work. The findings show that nurses are selective in their use of gatekeeping, depending on the perceived impact on patient care and the benefit that is accrued to nurses themselves.

Whiteboards: mediating professional tensions in clinical practice.

In this paper we argue that whiteboards in clinical settings play a hybrid role: communicating inter- and intraprofessional directives, mediating professional tensions, and mitigating potentially face-threatening acts. The data upon which this paper is based emanate from two independently conducted ethnographic studies: the first explored a range of nurse-nurse and nurse-doctor communication practices in operating rooms, while the second explored work routines and communication methods in oncology wards. Data collection included fieldwork using observations, interviews assisted by photographic methods, and in the first study, a personal diary. A deconstructive analysis was independently undertaken. As a communication method, the use of whiteboards in clinical settings provided a focal point for the coordination of clinical work activities and for the dissemination of information to large groups of people. Whiteboards were a conduit for potentially face-threatening information in that they facilitated the policing and disciplining of staff, while distancing communicators from one another. We conclude that whiteboards are 'pseudo-synchronous' in nature, enabling 'communication at a distance'. In doing so, whiteboards may facilitate and economize clinical communication but they also perpetuate the invisibility of nurses' contribution to ensuring safe care, and they mask the symbolic violence that is committed within and between health professionals.

Development and validation of the self-administration of medication tool.

BACKGROUND: Consumer participation in planning and implementing health care is actively encouraged as a means of improving patient outcomes. In assessing the ability of patients to self-medicate, health professionals can identify areas in which patients need assistance, education, and intervention to optimize their health outcomes after discharge. OBJECTIVE: To develop and validate a tool to quantify the ability of patients to administer their regularly scheduled medications while they are hospitalized. METHODS: Past research enabled us to develop the Self-Administration of Medication (SAM) tool. Using a Delphi technique of 3 rounds, a panel of expert health professionals established the content validity of the tool. For determining level of agreement in using the SAM tool, 56 patients were selected; for each patient, 2 randomly selected nurses completed an assessment. Construct validity and internal consistency were examined by testing the tool in 50 patients and comparing with other validated scales. RESULTS: The 29-item SAM tool had high content validity scores for clarity, representation, and comprehensiveness, with content validity index values ranging from 0.95-1.0. In testing the level of agreement between 2 nurses, out of 43 valid cases, 95.3% of nurses overwhelmingly agreed about the patients' competence to self-administer their drugs. The intraclass correlation coefficient was 0.819 (95% CI 0.666 to 0.902). Internal consistency for the SAM tool was high, with a Cronbach's alpha of 0.899. A moderate to strong correlation was obtained when comparing the SAM tool with other validated measures. CONCLUSIONS: The SAM tool is valid and reliable for quantifying patients' ability to manage their regularly scheduled medications in the hospital setting.

Governing time in operating rooms.

AIM: This paper examines how time is controlled and governed in operating rooms through interpersonal communication between nurses and doctors. BACKGROUND: Time is a valuable commodity in organizations with improvements often directed towards maximizing efficiencies. As a consequence, time can be a source of tension and interpersonal conflict as individuals compete for control of its use. METHODS: The data in this paper emanate from an ethnographic study that explored a range of communication practices in operating room nursing. Participants comprised 11 operating room nurses. Data were collected over two years in three different institutional settings and involved participant observation, interviews and the keeping of a personal diary. A deconstructive analysis of the data was undertaken. RESULTS: Results are discussed in terms of the practices, in which clinicians are engaged in, to govern and control their use of time. The four practices presented in this paper include; questioning judgment and timing, controlling speed, estimating surgeons' use of time and coping with different perceptions of time. CONCLUSIONS: Time and speed were hotly contested by nurses. They used their personal knowledge of individual surgeon's habits of time to govern and control practice. Nurses thought about surgeons in terms of time and developed commonly accepted understandings about the length of surgical procedures. They used this knowledge to manage the scheduling of operations in the departments and to control the workflow in individual operating rooms. Knowledge of individual surgeons was a source of power for operating room nurses. RELEVANCE TO CLINICAL PRACTICE: Nurses have more power in the operating room than might be imagined but they exercise this power in subtle ways. If operating rooms are to work effectively, the operating room team must understand each others' work better.

Governance in operating room nursing: nurses' knowledge of individual surgeons.

This paper explores governance and control in operating room nurses' clinical practice. Traditionally, operating room nurses have been portrayed as "handmaidens" to the surgeons, a position which implies that nurses' bodies and the knowledge they use in practice are sites of discursive control by others. This paper unsettles this understanding by showing how operating room nurses studied ethnographically in an Australian setting are both disciplined by and actively shape practice through knowing surgeons' technical requirements for surgery, through inscribing them in discourses of time, and through having deep knowledge of the surgeons' "soul". We argue that as a form of governance, nurses' knowledge of surgeons is a subjugated form of knowledge, located low down on a hierarchy of knowledges. Furthermore, as a form of governance that has previously been unarticulated in the literature, it transcends the traditional lines of authority and control in the nurse-doctor relationship. The data in this paper are drawn from an ethnographic study that explored a range of nurse-nurse and nurse-doctor communication practices in operating room nursing.

Rethinking theatre in modern operating rooms.

Metaphor is a means through which a widely accepted meaning of a word is used in a different context to add understanding that would otherwise be difficult to conceive. Through etymological and metaphorical associations, we contend that aspects of "theatre" are still relevant in the modern operating rooms and that the use of dramaturgical metaphors can add another layer of understanding about the social reality in this setting. We begin by exploring the historical roots and derivation of the word theatre as it applied to anatomical dissection and surgery. Briefly, we touch on the work of Erving Goffman and examine how his work has been used by others to explore aspects of operating room nursing. Then, drawing on data from a postmodern ethnographic study that has been used to examine communication in operating room nursing, four dramaturgical metaphors are used to illustrate the argument. They are drama, the script and learning the lines, the show must go on, and changing between back stage and front stage. To conclude, the small amount of previously published literature on this topic is compared and contrasted, and the relevance of using dramaturgical metaphors to understand modern operating rooms is discussed. Being able to distinguish between the inherent drama in operating room work and the dramatic realisation of individuals who work within, can help operating room nurses to think differently about, and perhaps re-evaluate their social situation and how they function within it.

A randomized controlled trial to measure the effectiveness of a sacral wedge in preventing postoperative back pain following trans-urethral resection of the prostate (TURP) in lithotomy position.

BACKGROUND: Postoperative back pain is a common, yet under reported, complication of surgery. Previous studies, although small in number, have indicated that the use of a sacral wedge is effective in reducing the incidence of postoperative back pain. AIM: The aim of the study was to test the hypothesis that the intra-operative use of a sacral wedge would decrease the incidence of postoperative back pain in patients undergoing trans-urethral resection of the prostate in lithotomy position. METHODS: The design of the study was a randomized controlled trial involving the use of a sacral wedge intra-operatively in a male population undergoing trans-urethral resection of the prostate. A total of 236 participants was recruited to the study and allocated to the control or intervention group by block randomization. All patients selected one of three different sized sacral wedges for use during surgery. Data were collected preoperatively, intra-operatively and at postoperative days 2 and 4 and the tools included a structured questionnaire, Oswestry Disability Questionnaire, a visual analogue scale to measure pain intensity and a body map to record its location. RESULTS: Fifty-two per cent of participants reported having a history of back pain and point prevalence on admission to hospital was 27%. Twenty-eight per cent of participants experienced back pain on day 2 postoperatively and this decreased to 14% on day 4. There was no significant difference between the control and intervention groups. The severity of back pain increased after surgery. Postoperatively there were reports of back pain from participants who had not reported a history of back pain before their admission for surgery. CONCLUSIONS: In contrast to other studies we found no evidence to support the use of a sacral wedge intra-operatively to reduce the incidence of postoperative back pain. RELEVANCE TO CLINICAL PRACTICE: Despite the non-significant results, the high level of postoperative back pain stills draws attention to the need to develop strategies to reduce its incidence.

The uses of photography in clinical nursing practice and research: a literature review.

AIMS: The aim of this paper is to report a study to identify themes and provide a 'snap-shot' of the scope and uses of photography in clinical nursing practice and research. BACKGROUND: Despite the dominance of vision as a way of understanding the world in Western societies, the applications of photography in clinical nursing practice and research have not been well synthesized or reported in the literature. METHODS: A computerized search of CINAHL database was performed using the terms photographs, photography, photographic, photovoice, videorecording and videotaping. Hand searching for additional citations was also undertaken. FINDINGS: The identified papers on photography were categorized into broad themes that reflected the different applications to which photography had been applied: documentation and surveillance; therapeutic intervention; teaching, learning and evaluating performance; research methods; and descriptive and instructional literature. Approaches to the use of photography, as recorded in the nursing literature, are broad and include: wound surveillance, covert patient surveillance, photo essay, art therapy, self-portraits, life albums, simulated recall, participant observation, photovoice, photo hermeneutics, production of research scenarios, and video modelling. CONCLUSIONS: The most common applications of photography in nursing and related journals include photo elicitation to promote understanding in research, videorecording as a method of teaching and learning, and as a method of observation, with more creative approaches tending to be employed in health professions other than nursing. Few reports gave explanations of how researchers negotiated ethical concerns when seeking approval for studies in clinical settings, and few gave details of the processes of data analysis.

Self-administration of medication in hospital: patients' perspectives.

BACKGROUND: Little information is available about patients' perspectives on self- or nurse-related administration of medication. AIM: The aim of the study was to determine patients' perspectives about self-medication in the acute care setting. METHODS: A qualitative approach, using in-depth semi-structured interviews, was taken. Ten patients with a chronic medical illness who had experienced multiple hospital admissions for treatment were interviewed about their experiences of medication administration in the acute care setting. Participants were recruited from two cardiovascular wards in a private, not-for-profit hospital in Melbourne, Australia. Data collection occurred between August and September 2002. FINDINGS: Four major themes were identified from the interviews: benefits of self-administration, barriers to self-administration, assessing appropriateness of self-administration and timing of medication administration. Seven participants had previously experienced self-administration of medications and six were in favour of this practice in the clinical setting. Nine managed their own medications at home, and one self-administered with some assistance from his family. Participants were very concerned about how nurses' heavily regulated routines affected delivery of medications in hospital and disrupted individualized plans of care maintained in the home setting. CONCLUSIONS: In planning and implementing self-administration programmes, it is important to consider patients' views. Medication regimes should be simple and flexible enough to adapt to patients' lifestyles and usual routines. Nurses should also take advantage of opportunities to support and facilitate patient autonomy, to enable more effective management of health care needs when patients return home.

Identifying lost surgical needles using radiographic techniques.

Many surgical procedures involve the use of very small surgical needles. In the event that a postoperative needle count is incorrect, traditionally an x-ray has been taken to find the needle. Little data exist to recommend the smallest surgical needle that can be identified with conventional radiographic techniques and the optimum technique for finding lost surgical needles. In this quality assurance project x-rays of various size surgical needles were taken. The smallest seen by the majority of observers was 17 mm. The radiographic technique of choice for optimum detection of lost surgical needles was imaging with a mobile image intensifier.

Snap-shots of live theatre: the use of photography to research governance in operating room nursing.

The use of photography is an underreported method of research in the nursing literature. This paper explores its use in an ethnographic research project, the fieldwork of which was undertaken by the first author. The aim was to examine the governance of operating room nursing in the clinical setting and the theoretical orientation was the work of Michel Foucault. The focus of this paper is on how photography was used as a means of data generation. To establish some context we begin by drawing on writers from sociology and anthropology to provide an overview of the status of vision and visual research methods in contemporary social research. We then move to a brief discussion of the uses of photography in social research and the limitations imposed by ethical considerations of its use in clinical nursing settings. As well, the process and approach involved in this research project, and issues of analysis are discussed. Three 'snap-shots' of operating room nursing, taken by participants, are presented. Each is analysed in terms of its contributions to the research process as well as its substantive contribution to the theoretical framework and the research aims.

Foucault could have been an operating room nurse.

BACKGROUND: Operating room nursing is an under-researched area of nursing practice. The stereotypical image of operating room nursing is one of task- and technically-orientated aspects of practice, where nurses work in a medical model and are dominated by constraints from outside their sphere of influence. This paper explores the possibility of understanding operating room nursing in a different way. AIM: Using the work of Michel Foucault to analyse the work of operating room nursing, this paper argues the relevance of the framework for a more in-depth analysis of this specialty area of practice. CONTENT: The concepts of power, discipline and subjectivity are used to demonstrate how operating room nursing is constructed as a discipline and how operating room nurses act to govern and construct the specialty. Exemplars are drawn from extensive professional experience, from guidelines of professional operating room nursing associations, as well as published texts. The focus is predominantly on the regulation of space and time to maintain the integrity of the sterile surgical field and issues of management, as well as the use of the ethical concept of the 'surgical conscience'. CONCLUSIONS: This form of analysis provides a level and depth of inquiry that has rarely been undertaken in operating room nursing. As such, it has the potential to provide a much needed, different view of operation room nursing that can only help to strengthen its professional foundations and development.

Establishing the shelf life of flexible colonoscopes.

This study was designed to establish a shelf life for processed (peracetic acid) flexible colonoscopes and to demonstrate the adequacy of manual cleaning procedures. The study challenges current practice in Australia where endoscopes are routinely reprocessed prior to use if the endoscope has been sitting at least overnight. The design was a simulated study in the clinical environment and involved artificial contamination of a colonoscope, cleaning validation, and a time series analysis after processing with peracetic acid in a Steris System 1 processor and drying with 100% isopropyl alcohol. The main outcome measure was the presence of bacteria in the internal channels of the colonoscope after cleaning and at 24 and 168 hours after processing with peracetic acid. The findings suggest that colonoscopes may be left for up to 1 week before needing to be reprocessed before use, provided all channels are thoroughly reprocessed and dried, resulting in cost savings and reduced wear and tear on the instruments. The findings also demonstrate the impact of providing feedback to staff on a regular basis about the efficacy of their cleaning techniques.