‘Watching’ an operation


Laparoscopic surgery has become one of the predominant ways to operate on patients. In this form of surgery, surgeons are not directly looking at the patient. Rather, surgeons look at a mediated image of the patient’s body cavity as recorded by a camera (a laparoscope) and displayed on a screen. These screen-based operations pose new kinds of opportunities and challenges for visual attention and communication during operations. Also scrub nurses, who are in charge of instrument passing to surgeons, usually gaze at these screens. Yet, less is known about the role of the screen for these nurses. Do the images displayed on the screen have the same “significance” for nurses as they have for surgeons? screen

Clearly, instrument passing from a scrub nurse to a surgeon requires monitoring of the operation. Specific instruments are needed at different stages of the operation, and the nurse is expected to know the operation and the procedures involved well. They are often expected to remain one step ahead of surgeons, who might not always say what they need (but, for example, put their hand out while expecting an instrument to be passed). In laparoscopic operations, then, does the scrub nurse determine the timing of instrument passing from the images seen on the screen? This issue has to be re-examined carefully, as scrub nurses’ training rarely involves explicit instruction about how to follow a screen-based operation. Through an analysis of video recordings and a detailed transcription of instrument passing episodes, I have found that before a nurse presumably “realises” that an instrument should be transferred to the surgeon, they orient to the subtle movements of the surgeon – for example, the surgeon’s posture shift – that occur in the nurse’s peripheral vision. As such, the laparoscopic images might not be the only source of information for the scrub nurse, even so if they are ostensibly gazing at the screens. “Body reading” is just as important.

Screen 2

Here the nurse drops her gaze from the screen in response to the surgeon’s posture shift towards the patient. Shortly after, the nurse passes a syringe (in a dish she is holding) to the surgeon. 

Mobilising a team for the WHO Surgical Safety Checklist

My new study is out today in the BMJ Quality & Safety.


Background. One challenge identified in the Surgical Safety Checklist literature is the inconsistent participation of operating teams in the safety checks. Less is known about how teams move from preparatory activities into a huddle, and how communication underpins this gathering. The objective of this study is to examine the ways of mobilising teams and the level of participation in the safety checks.

Methods. Team participation in time-out and sign-out was examined from a video corpus of 20 elective surgical operations. Teams included surgeons, nurses and anaesthetists in a UK teaching hospital, scheduled to work in the operations observed. Qualitative video analysis of team participation was adapted from the study of social interaction.

Results. The key aspects of team mobilisation were the timing of the checklist, the distribution of personnel in the theatre and the instigation practices used. These were interlinked in bringing about the participation outcomes, the number of people huddling up for time-out and sign-out. Timing seemed appropriate when most personnel were present in the theatre suite; poor timing was marked by personnel dispersed through the theatre. Participation could be managed using the instigation practices, which included or excluded participation within teams. The factors hindering full-team participation at time-out and sign-out were the overlapping (eg, anaesthetic and nursing) responsibilities and the use of exclusive instigation practices.

Conclusions. The implementation of the Surgical Safety Checklist represents a global concern in patient safety research. Yet how teams huddle for the checks has to be acknowledged as an issue in its own right. Appropriate mobilisation practices can help bringing fuller teams together, which has direct relevance to team training.

In the Finnish Medical Journal

An interview based on our music study was published in the Finnish Medical Journal (Suomen Lääkärilehti 36/2015).

About the journal (from Suomen Lääkärilehti website):

“Suomen Lääkärilehti (Finnish Medical Journal) is the leading journal aimed at doctors in Finland. The journal is published by the Finnish Medical Association, the professional organization for doctors with a membership of 95 % of all doctors registered in Finland. Apart from doctors the readership of the journal includes other health-care personnel, pharmacy staff, staff of companies in the health-care field and future doctors, i.e. medical students.

Suomen Lääkärilehti disseminates new medical information, functions as a journal for continuing education and professional proceedings for doctors. It monitors trends in health care and health-care policy and serves as a forum for professional information and discussion. As a membership journal it also functions as a medium for professional discussion and other information needed by doctors.”

Music and communication in the operating theatre

On 5th August, many newspapers in the UK reported on negative aspects of playing music in the operating theatres. guardian photo
I am a co-author on this observational study, published in the Journal of Advanced Nursing.

Our video-based research found that surgeons had to repeat their instructions to nurses more frequently when music was playing during surgical operations.

This meant that music got loud enough to impair communication: nurses did not always hear the requests issued for instruments, supplies or other assistance. The need for repeated information led to visible frustration or tension within some of the teams.

Why is there any music in the operating theatre? Many surgeons highlight that music can bring comfort to patients. Indeed, some literature suggests that music can be beneficial during awake surgery by reducing anxiety levels in patients.

Music is also played when patients are fully anaesthetised. As patients are asleep, music is played for the clinical staff rather than the patients. These are the kind of operations we observed.

A body a work suggests that surgeons perform better when music is playing: it can help concentration and make surgeons operate faster. Some surgeons tell us how music masks white noise and other distracting talk in the theatre. It can also fill silence.

During our fieldwork in a London teaching hospital, we noted that music was often played through mobile phones and iPods, with modern theatre suites being equipped with docking stations and speakers. Sometimes volume could change rapidly between songs; sometimes staff turned up the volume on a popular song.belfast telegraph

We observed how music and increasing volume had an impact on team communication. Usually when music got fairly loud, nurses started to prompt surgeons to repeat themselves, as instructions or requests were not properly heard over the music. There were times when music was deliberately turned up, notably when surgeons were finishing off an operation. Yet, this was critical time for nurses, who were undertaking counts for the instruments and swabs used in the operation. It is imperative that nurses can hear each other properly during the counts, as any mistakes can become costly to patient safety: retained surgical items are more common than thought. techinews photo

The key is to understand both the benefits and losses of playing music in the operating theatre. Without a doubt, music can be beneficial at an individual level to those surgeons who prefer to listen to their favourite tracks while operating. However, when not controlled, music can have a less desirable impact at the team level, when instructions go unnoticed or are picked up slowly. Some team members can be more sensitive to loud music; hard of hearing problems can make it more difficult to work in an environment with additional noise.

Key message: Regulations for music in the operating theatre

Our study recommends regulations so that music will not hamper teamwork and potentially jeopardise patient safety. Currently no formal regulations are in place regarding music, as checked with the Royal College of Surgeons of England, Royal College of Nurses, and Royal College of Anaesthetics.

imperial press release photoThe regulations can be simple with a view to preserving music in the operating theatre, if teams so wish:

1. Teams should review the playing of music at the start of each operation. The ‘time-out’ period of the Surgical Safety Checklist could provide an excellent opportunity for team discussion and voicing out any concerns some might have.

2. There ought to be a cap on the volume control ensuring that music stays in the background, creating a sound work environment for all.

We are hoping to open up wider discussion, including operating theatre professionals, clinical managers, clinical educators, and policy makers. We invite nurses to join the discussion, as the views on music in the operating theatre are currently heavily represented by surgeons.

Listen to the editor Roger Watson discussing our paper in the podcast of the Journal of Advanced Nursing.

Video-Supported Simulation for Interactions in the Operating Theatre (ViSIOT)

visiot imageIn an article published in Clinical Simulation in Nursing, we’ve introduced our training model, Video-supported Simulation for Interactions in the Operating Theatre (ViSIOT).

This article introduces a data-grounded simulation model for training social interaction strategies to operating theatre nurses. Video-Supported Simulation for Interactions in the Operating Theatre draws on original video-based research on teamwork in the operating theatres in the United Kingdom. The objective of this model was to improve verbal and nonverbal interactions between nurses and surgeons that often fall outside explicit training. These involve visual monitoring of colleagues, verbal responsiveness, speaking up about distractions, and seeking prompt clarification when needed. The model includes two scenarios and video-supported debriefing, which uses authentic research footage from the operating theatres. In the article, the strategies are briefly communicated and implications for training are discussed.

Korkiakangas, T., Weldon, S. M., Bezemer, J., & Kneebone, R. (2015). Video-Supported Simulation for Interactions in the Operating Theatre (ViSIOT). Clinical Simulation in Nursing11(4), 203-207.


From research to practice

As part of my Fellowship, I am developing a training model for operating theatre professionals. It is important for me to try and improve these workplace interactions by working with the new generation of nurses, surgeons and ODP’s, who are still in training, but also with those who are already in service. It’s offering something back to the professional groups I have been observing.

A prototype of the training model is already in place. On the basis of our findings in the “Transient Teams” project, we organised training days for student nurses and ODP’s at a Health and Social Care department in a London university. We developed scenarios on the basis of the examples we encountered in our video data. These represented real communication issues during surgical operations, ranging from dealing with distractions (e.g., loud music) to verbally responding to calls for assistance. I’ll illustrate the latter with an example:

Consider that a surgeon is busy operating and then calls out that he or she needs particular supplies, which are not readily available in the theatre. On hearing this request, it would be good practice for a nurse (often the circulator or “runner” nurse) to verbally acknowledge it before nipping out to the store room. coming up

Sounds obvious? You respond when something has been asked from you. Well, we found that quite often there is a lack of verbal responsiveness to colleagues, especially if the request involves something mundane. Like retrieving sutures, turning the gas on, or switching green lights on for the surgeon. That is, although people are busy doing what has been asked of them, verbal responses or updates are often left out. And that can become problematic.

Sometimes we have witnessed lengthy halts to operations because of these “silences”: the surgeon believes no one has heard them, stops operating, and turns around to look for a nurse. Clearly, nurses and surgeons are all busy. Interactions don’t always work as ideally as we’d like them to, especially when people are immersed in their work. And circulating nurses are routinely multitasking, attending to several concerns at once, assisting not only surgeons but also the scrub nurse.

The key is to consider how we often take communication for granted. Can we develop solution strategies for practices that clearly are not working? In the training program, we simulate these examples with students and discuss them openly in debriefing sessions. Using examples of our (research) video data, we offer the students an opportunity to observe how these examples unfold in real operations: what happens when a nurse does not respond verbally to a surgeon, and what happens when they do respond. Importantly, the training model is not based on hypothetical scenarios, but on real routine-like practice.

Communication in the Operating Theatre

Communication in the Operating Theatre. Weldon, S-M., Korkiakangas, T., Bezemer, J. & Kneebone, R. (2013).
 British Journal of Surgery, 100(13), 1677-1688.

Background: Communication is extremely important to ensure safe and effective clinical practice. A systematic literature review of observational studies addressing communication in the operating theatre was conducted. The focus was on observational studies alone in order to gain an understanding of actual communication practices, rather than what was reported through recollections and interviews.

Methods: A systematic review of the literature for accessible published and grey literature was performed in July 2012. The following information was extracted: year, country, objectives, methods, study design, sample size, healthcare professional focus and main findings. Quality appraisal was conducted using the Critical Appraisal Skills Programme. A meta-ethnographic approach was used to categorize further the main findings under key concepts.

Results: Some 1174 citations were retrieved through an electronic database search, reference lists and known literature. Of these, 26 were included for review after application of full-text inclusion and exclusion criteria. The overall quality of the studies was rated as average to good, with 77 per cent of the methodological quality assessment criteria being met. Six key concepts were identified: signs of effective communication, signs of communication problems, effects on teamwork, conditions for communication, effects on patient safety and understanding collaborative work.

Conclusion: Communication was shown to affect operating theatre practices in all of the studies reviewed. Further detailed observational research is needed to gain a better understanding of how to improve the working environment and patient safety in theatre.