Briefings in surgical teams: a pilot study of experiences and attitudes.

While healthcare should not be compared to other high reliability organisations (HROs), many lessons, attitudes, and transferable practices can be applied and adapted from them to improve patient safety and team morale. Despite briefings improving both patient safety and effective team working, some in healthcare have not valued or actively engaged with them, deeming them to be irrelevant. In this pilot study we explored the experiences of, and attitudes to, briefings using a 10-question Survey Monkey. This was promoted during a human factors session at the 2023 Association of Surgeons in Training Conference (ASiT) and at a large NHS trust. Questions were asked about the number of briefings per day, attitudes, engagement, and respondents' attitudes to them. In total, 109 responses were received. A total of 85% reported at least one briefing on a normal operating day, 65% felt them to be interactive, 67% reported that briefings were led by the most senior surgical team member, and 58% lasted four minutes or more. Eighteen per cent of respondents felt they were of little benefit, and 56% did not routinely de-brief at the end of the day. This study has highlighted variable attitudes to team briefings, with some colleagues still seeing them as a 'tick box' exercise. While culture has changed following the introduction of the WHO checklist, the importance of active engagement and education to improve the delivery and value of effective briefings cannot be overestimated. It is also an opportunity to create a 'safe space' for team members and to confirm zero tolerance for any inappropriate behaviour, including sexual misconduct.

Abbreviation use decreases effective clinical communication and can compromise patient safety.

Clear communication is paramount for achieving the safest and best patient outcomes, for maximising time efficiency, and lowering clinician workload. Multiple factors contribute to communication efficacy, including knowledge of topics between those communicating, interpersonal familiarity, and available time. Information exchange is growing faster and more frequent due to evolving communication technology, and communication is expanding as a response to increasing workloads. The number of referrals between specialties and the general practitioner (GP) is rising. The use of abbreviations has expanded in clinical communications and is likely to lead to misunderstanding, increased workload, and worse patient outcomes. In this article, we explore the use of abbreviations in the clinical setting.

Caffeine: benefits and drawbacks for technical performance.

Surgical and minimally-invasive procedures, including cardiac and radiological, have high-stake patient outcomes. Working pressures, altering shift rotas, and ever-increasing demands have led to worsening sleep patterns for surgeons and allied professionals. Sleep deprivation alone has harmful consequences in relation to clinical outcomes and the physical and mental health of the surgeon, and to offset fatigue, some surgeons use legal stimulants such as caffeine and energy drinks. This stimulant use, however, may come at the cost of negative effects on cognitive and physical function. We aimed to explore evidence behind the use of caffeine, and its consequences on technical performance and clinical outcomes.

Briefings: what can surgical and minimally invasive interventional teams learn from airline flight deck practice?

While healthcare should not be compared to aviation or indeed other high reliability organisations (HROs), many lessons, attitudes, and transferable practices can be applied and, more importantly, adapted from them to improve patient safety and team morale. The team brief before any interventional list is one such process that can have a significant effect on the delivery and safety of patient care and effective team working. Due to NHS pressures and the perception by some in healthcare that the time taken to conduct a full team briefing has little importance, it can sometimes be rushed or regarded as a 'tick box' process that delays a list. However, when used appropriately, the briefing is a chance to lower authority gradients and thereby improve patient safety. It also reduces the likelihood of medical errors, builds and improves situational awareness by considering various 'what-if' scenarios and how they will be dealt with, and considers wider issues including potential distractions. An important outcome is its effect on team morale through empowerment, and it is an opportunity for learning. In this article, which has been written following a unique opportunity to observe a full team brief on an Airbus A380 flight deck, we consider how, through the thorough use of checklists, briefings can be used to best advantage for interventional teams. We raise the question 'would you engage differently with the briefing if your own life or procedure depended on it?'

Pilot study to evaluate safety culture perception in the operating theatres of an acute NHS Trust using the National Air Traffic Services (NATS) App.

An area critical to safety in an organisation is the perceived and actual culture. National Air Traffic Services (NATS) work closely with large safety-critical industries including various aviation companies to enable them to identify strengths and vulnerabilities with the aim of improving safe practice. NATS have developed a simple free downloadable self-assessment App that individuals can use to assess their own culture perception in their organisation. The App has 16 questions arranged in four domains but to our knowledge it has not been used to date in healthcare. As part of the initiatives to improve staff culture, we evaluated operating theatre colleagues' safety perception in our large acute NHS Trust in a pilot study using the NATS safety App. Staff downloaded the App to their smart device before completing it. Responses were sent anonymously through the App and collated by NATS. A total of 146 colleagues downloaded and completed the questionnaire. One hundred and seventeen staff (80%) felt encouraged to report safety concerns, but 86% (n=126) confirmed a lack of available support from healthcare managers. Only 43% of respondents (n=63) would find it easy to challenge colleagues if they observed unsafe behaviour. This pilot study has identified positive indicators of an evolving NHS safety culture, and some concerns about speaking up, support, and challenging colleagues without fear. These issues are known to occur across healthcare. Further work is needed in the NHS to provide a supportive environment to improve patient safety, and lower hierarchy in surgical teams.

Virtual postgraduate exams and assessments: the challenges of online delivery and optimising performance.

The COVID-19 pandemic has catalysed the computerisation and online delivery of postgraduate examinations. Social distancing regulations and lockdown measures resulted in many written and clinical examinations being cancelled during the initial surge of the virus. In an effort to reinstate the assessment of trainees and enable career progression, the UK medical regulator, the General Medical Council (GMC) has approved unprecedented changes to clinical examinations, including virtual assessment. We outline the changes made and the advantages and disadvantages of these new examination formats. We discuss ways for candidates and examiners to optimise their virtual environment and develop skills that can improve performance.

Virtual ARCP assessment and trainee feedback meetings: facilitating the best experience and practice.

As a result of COVID-19, there has been an exponential increase in the use of remote technology for many local, regional and national meetings that would previously have been held on a face-to-face basis. Remote meetings have ensured that essential clinical, educational and strategic work can continue but it is not 'business as usual', although colleagues accept this form of communication as the new norm. In medical education and assessment, the Annual Review of Competence Progression (ARCP) meetings and other formative educational meetings are being conducted remotely. This form of communication has some advantages but may also present possible barriers for feedback and development particularly for 'trainees in difficulty' when there are concerns about progression, and when an unsatisfactory outcome has been awarded. It is also worth remembering that there may be generational differences with the ease of use of virtual meeting platforms. We present some of the important factors for optimising the panel of virtual ARCPs and discuss methods to improve feedback given remotely for trainees.

You Have Control: aviation communication application for safety-critical times in surgery.

High-risk organisations (HRO), including aviation, undergo formal communication training, with emphasis on safety-critical moments. Such training is not widespread or mandatory in healthcare, and while there are many differences both share the 'human element' with circumstances leading to an increased risk of harm. A typical operating theatre consists of an operating surgeon, and an assisting surgeon, roles that may change throughout the course of a procedure. Similarly, a training aircraft or multi-crew cockpit (flight deck) has a pilot in control, or 'pilot flying', and a 'pilot not flying'. Both interact with wider teams, for example the scrub team and air traffic controllers, respectively. Surgical error is the second most prevalent cause of preventable harm to patients after drug errors. Every year in the UK National Health Service (NHS), there are typically 500 never events, 21,000 serious incidents, and many more episodes of physical or psychological harm. Ineffective communication (46%) is the most common behavioural factor leading to a never event. In this review, we examine the concept of 'sterile cockpit', use of unambiguous terminology, callsigns, important information readback, sharing of mental models, and the mini-brief, and how these may be used to reduce patient harm during safety-critical moments.

Human factors recognition at virtual meetings and video conferencing: how to get the best performance from yourself and others.

During the current coronavirus pandemic, social distancing and restrictions on travel have resulted in a dramatic rise in the use of technology (including video conferencing) for remote meetings. From local multidisciplinary team (MDT) meetings to national and international committees, this form of communication has been vital to ensure patient-related and other business can continue, albeit in a sometimes unfamiliar environment. In this article we consider some of the human factors elements of remote meetings and provide suggestions to enhance the experience of team and committee members during this unsettling time. It is possible that this form of communication will continue to flourish after the pandemic is over.

Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.

Review: Avoid, trap, and mitigate - an overview of threat and error management.

Human error is as old as humanity itself and occurs on a daily basis, whatever we are doing. Recognising our fallibility is the first step to understanding error and ways to reduce it. The term "never event" is, therefore, a misnomer as these serious adverse incidents can never be eliminated completely. Up to 1 in 20 hospital admissions includes some form of error, and while many have little detrimental effect on patients' care (such as forgetting to write a discharge summary), 6% are serious. Many medical errors could have been prevented through the understanding and application of human factors (HF) including (but not exclusively) better team working, situational awareness, and the lowering of authority gradients. In this article we provide an overview of error and introduce the concept of threat and error management (TEM) which is used in other, high-reliability organisations, and provides three layers of defence to reduce the effect or severity of any error. We discuss how to try and avoid medical error in the first place (the first line of defence), trap errors when they occur, and mitigate the consequences of any error to help further safeguard our patients.

The impact and effect of emotional resilience on performance: an overview for surgeons and other healthcare professionals.

Medicine and surgery can be demanding professions with high levels of burnout, but few healthcare professionals are given training or education in the management of stress, and the ability of individuals to cope with work and other pressures is often taken for granted. Emotional resilience - the ability to recover from a stressful event, whether at work or at home - is influenced by factors that are both within and outside our control. In this review, we provide an overview of emotional resilience for surgeons and other healthcare professionals, and focus on the factors that can be modulated to help us cope with difficult or complex situations. We also discuss the importance of teamwork and camaraderie, which can easily be forgotten in busy working practice. A greater awareness and understanding of emotional resilience and ways to cope with stress and pressure at work are essential if we are to look after ourselves better, improve the work of our teams, and provide the best care for our patients.

Sleep: its importance and the effects of deprivation on surgeons and other healthcare professionals.

As clinicians, we sometimes fail to look after ourselves properly and do not regularly eat healthy foods or drink enough. Sleep is another factor that we often neglect. A lack of it can compromise our personal health and performance at work, and the "sleep debt" that results when this is chronic can take far longer to recover from than one might think. Now that junior doctors work more shift rotas and senior colleagues have onerous on-call responsibilities, we all need to be aware of the effects of sleep deprivation, which can lower the mood and motivation, weaken leadership, and result in more clinical errors. In this review we consider what might constitute enough sleep, the consequences of inadequate sleep, and how these might be addressed for surgeons.

Could exercise improve mental health and cognitive skills for surgeons and other healthcare professionals?

Workplace-related illness is common in the UK, and in healthcare more than five million working days over 10years have been lost as a result. Occupational stress is well known and can affect clinicians at any stage, yet many healthcare professionals continue to work with this or other psychological problems (including anxiety, chronic fatigue, and burnout) as they do not wish to let their colleagues down. Mental health issues might be dismissed, particularly in surgery, because there is a misconception that surgeons can cope better with stress than those working in other specialties, and are better protected from clinical burnout. The benefit of exercise on physical health is clear, but its role in the maintenance of good mental health and well-being should not be underestimated. As society adopts an increasingly sedentary lifestyle, exercise for many has a lower priority than other activities. In this article we give an overview of the mental health issues that might affect doctors and surgeons, and explore how exercise can benefit our well-being and clinical performance.

Can dietary supplements improve a clinician's well-being and health?

Many people use dietary supplements to improve their physical and mental well-being and their general health, but do not know if they really have any benefit. To our knowledge, little has been published on their use in the clinical environment, so we evaluated the evidence for their benefits in people whose work is physically and mentally challenging. Studies on nutrition and supplementation in athletes and military personnel have clearly shown that several compounds improve cognition, mental well-being, and physical performance. Based on this evidence, and with the many pressures faced by healthcare workers, as well as the need for concentration and endurance, some dietary supplements might be beneficial. Supplementation of a balanced diet with omega-3 fatty acids, vitamin B3, vitamin C and associated antioxidants, vitamin D, and protein, may improve a clinician's physical and mental health and their performance at work. Specific research is, however, needed to evaluate this more fully.

Impact of hydration and nutrition on personal performance in the clinical workplace.

As clinicians we sometimes fail to look after ourselves at work. We often do not drink enough during the day or miss lunch breaks while caring for patients, and this can be particularly evident during an all-day operating list when procedures are long and complex. Some operating theatre staff do not even eat breakfast regularly. Inadequate intake of fluids or nutrition can impair performance, lead to tiredness and headaches, and may compromise both our own health and the care we provide to patients. Other high-risk organisations, including aviation, have recognised that employees must look after themselves if they are to optimise their performance. In this review, we discuss the importance of adequate hydration and nutrition at work to raise awareness that this is essential if we are to provide the best care for our patients.