**3. Communicating with the team of care**

Surgery is a complex procedure that involves the patient, surgeon, anesthesiologist, nurses, technician, and relatives and for complete care of patient: nutritionist, physiotherapist, internist, radiologist, pathologist, radiotherapy experts, and many more. This complexity begins from the time the patient is admitted from outpatient, through ward, operating room, postoperative acute room, and back to the ward and follow up. It is this complexity that could lead to medical error as a result of miscommunication. The Agency for Healthcare Research and Quality (AHRQ) developed tools for communication among the surgical team that aligns the surgical care well. This is called TeamSTEPPS [37].

**d.** Giving patient information

44 Vignettes in Patient Safety - Volume 4

**ii.** "I am sorry to tell you that …"

ing empathic response in four steps.

such as

options.

**e.** Being empathetic

**f.** Strategy and summary

Words that express some form of warning before the bad news is given may prepare the patient, lessen the shock, and help in processing the information. This may be expression

Give medical fact by knowing the level of understanding and using correct vocabulary. Avoid excessive bluntness that may leave the patient isolated and later angry with a tendency to blame the surgeon-such language as—"your cancer is very bad and if not treated immediately you are going to die". Give information in small portion, check patient understanding at every step, and finally, even if prognosis is poor, avoid using phrases that discourage such as 'there is nothing we can do for you', because the goal of pain and symptom relief is still

This has been addressed above, but for emphasis, patient emotional reactions may vary from silence to disbelief, crying, denial, or anger. The physician can offer support by giv-

A clear plan and strategy may make the patient less anxious and more certain. However, the treatment options should be discussed with the patient who is 'available' emotionally. If the physician continues, it may appear like the physician's preferences are more important than patients. Shared decision-making model engenders shared responsibility and reduces sense of failure when treatment is not successful. Ensuring the patient has understood, document-

Surgery is a complex procedure that involves the patient, surgeon, anesthesiologist, nurses, technician, and relatives and for complete care of patient: nutritionist, physiotherapist, internist, radiologist, pathologist, radiotherapy experts, and many more. This complexity begins from the time the patient is admitted from outpatient, through ward, operating room, postoperative acute room, and back to the ward and follow up. It is this complexity that could lead

**i.** "Unfortunately, I have some bad news to tell you"

**i.** Take the cues that may include sadness, silence, or crying

**ii.** Confirm the emotions with the patient by open questions

**iii.** Confirm the reason for emotion, mostly connected with bad news

**iv.** Let the patient know you understand why they could be sad.

ing the finding, and recording all that is said and done are important.

**3. Communicating with the team of care**

The tool begins with at the structure of communication. The structure is called multi-team system for patient care. Team is defined as two or more people who interact dynamically, interdependently, and adaptively towards a common and valued goal, have specific roles or functions, and have a time-limited membership [37]. The core team is a group of care providers with the closest contact with the patient. They work interdependently to manage patients from point of assessment to disposition. In the case scenario of Ms. Rono, this would include Dr. Otieno, surgical resident, intern, and the ward nurse. Contingency team is a time-limited team formed for emergent or specific events and composed of members from various teams. This will be the operating room team or the code blue team: a team comprising members are responsible for managing the operational environment that supports the core team. Ancillary Services provide direct, task-specific, and time-limited care to patients while also support services provide indirect service-focused tasks which help to facilitate the optimal health care experience for patients and their families. This includes nutritionist, physiotherapist, and social workers [37].

The role of administrators is to establish and communicate vision, develop policies, and set expectations for staff related to teamwork, support and encourage staff during implementation and culture change, hold teams accountable for team performance, and define the culture of the organization. The patient is as the apex of the pyramid, indicating every team is involved in taking care of the patient (**Figure 1**).

The team structure is important because it identifies individuals among which information must be communicated, designates leaders, and mutual support is sought. In a complex scenario such as this, between-team communication and within-team communication about tasks and processes are important. Effectiveness of teams can be sabotaged by factors that are described by Lencioni in his book: The Five Dysfunctions of a Team. This includes inattention to results, avoidance of accountability, lack of commitment, fear of conflict, and absence of trust [38]. Therefore, team leadership with concomitant effective communication is key to patient safety in such context.

In this complexity, effective communication serves as the coordinating mechanism for the teamwork and is the lifeline of a well-functioning team. The skills to communicate effectively are essential for patient safety and are the mode by which most of the tools for TeamSTEPPS are executed. The sentinel event data reported by the Joint Commission between 1995 and 2005 indicate that ineffective communication was the root cause of 66% of the errors reported. The data from 2010 to 2013 indicate that ineffective communication remain among the top three causes of sentinel events [5].

Failure of communication within the team or department leads to failure to share information with the team, failure to request information from others, or direct information to a particular member of the team and also failure to include patients and their families in communication involving their care. This will be indicated by poor documentation, that is not timed,

leaders who model communication to achieve team cohesiveness and effectiveness. This leads to better outcomes to the patient's and surgeon's satisfaction. For communication within and between teams to be effective, the leadership must have a style that facilitates it. A surgeon may have a disruptive style of communication that puts the patient at risk of mistakes during procedures. It interferes with cohesiveness and minimizes the chances of juniors raising concerns because the environment is not conducive. There are tools that have been developed to aid teams be effective in their communication, maintain their cohesiveness, and have clear explicit messages understood and accepted by all members of the team. These tools include

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 47

ISBAR is a tool that was developed for healthcare workers to communicate about a patient's condition. It helps organize one's thoughts to communicate clearly and completely [37].

It is post-mastectomy day one for Ms. Rono; her drainage tube is not working well and the mastectomy site is full because of hematoma/seroma. The patient is in pain. The nurse is notified and so she decides to escalate the problem to the surgeon. She would identify herself by her name and state that Ms. Rono has a postmastectomy hematoma; she is a patient who had right sided mastectomy the day before, and currently her drain is not working well. She has examined and found the mastectomy site to be swollen and warm and suggests that another

While doing this, the nurse and the doctor can use check-back or closed-loop systems that ensure that the message passed by the nurse is repeated to her by Dr. Otieno and she acknowledges and ascertains the message being passed; this helps in verification of the message. In situation where, for example, Ms. Rono has bled a lot and requires the resuscitation team, the nurse would have to use call-out, which means sending the message to all the members of the team at once. It is a method of sending critical information during an emergent event. The information is used to prepare the team members to anticipate what the situation is and how to act. Usually the team leader may distribute tasks that need to be performed to specific members; the check-back confirms that the team member has received and understood the

Most of the hospital staff works in shifts, and it has been noted that most of the adverse events occur during this change-over period. If the nurse in the morning had noticed the hematoma and because of distraction had not called and fails to notify his or her colleagues in the next shift, that patient may not be attended to until she requires resuscitation, if the bleeding remains active. To avoid such events, there is a tool used for handoffs, which aims to provide

ISBAR, call-outs, handoffs, and check-backs.

B-Background of the patient condition and current status.

I-Introduce yourself.

**3.2. Case scenario**

drain would help.

message [37].

S-Situation that has made you call.

A-assessment that has led to the concern.

R-Recommendation for the condition.

**Figure 1.** Multiple team systems.

nonspecific, and incomplete and failure to seek input from the patient. In case of automated systems, it will also lead to inconsistencies in the utilization of the system [37].

Effective communication is complete, clear, timely, and brief. Complete means communicating essential information without giving details that may cause confusion and letting the receiver have an opportunity for clarification. Clear information is one that uses plain language that can be understood by patients and relatives or standard terminologies understandable to every healthcare provider. Brief means being concise and to the point and timely implies being dependable to offer and seek information, without delays in relaying or getting information that could compromise patient care, recheck, and validate information [37].

Challenges to effective communication include language barriers, distractions such emergency, distance, and personalities that are difficult to communicate with, heavy workload and varying communication styles, and disagreement which may disrupt flow of information. Lack of verification and acknowledgement of received information and transitions in care of patient can lead to communication breakdown [37].

#### **3.1. Case scenario**

Ms. Rono, having been investigated, is now admitted for breast conserving surgery. However, the surgeon who saw her at outpatient is called for an emergency. The trainee assumes that mastectomy would be better without reference to patient or Dr. Otieno, so they perform mastectomy instead of breast conserving surgery.

This scenario is common where there is no clear and effective communication. A number of tools have been developed for communication in varying scenarios. Effective teams are led by leaders who model communication to achieve team cohesiveness and effectiveness. This leads to better outcomes to the patient's and surgeon's satisfaction. For communication within and between teams to be effective, the leadership must have a style that facilitates it. A surgeon may have a disruptive style of communication that puts the patient at risk of mistakes during procedures. It interferes with cohesiveness and minimizes the chances of juniors raising concerns because the environment is not conducive. There are tools that have been developed to aid teams be effective in their communication, maintain their cohesiveness, and have clear explicit messages understood and accepted by all members of the team. These tools include ISBAR, call-outs, handoffs, and check-backs.

ISBAR is a tool that was developed for healthcare workers to communicate about a patient's condition. It helps organize one's thoughts to communicate clearly and completely [37].

I-Introduce yourself.

S-Situation that has made you call.

B-Background of the patient condition and current status.

A-assessment that has led to the concern.

R-Recommendation for the condition.

#### **3.2. Case scenario**

nonspecific, and incomplete and failure to seek input from the patient. In case of automated

Effective communication is complete, clear, timely, and brief. Complete means communicating essential information without giving details that may cause confusion and letting the receiver have an opportunity for clarification. Clear information is one that uses plain language that can be understood by patients and relatives or standard terminologies understandable to every healthcare provider. Brief means being concise and to the point and timely implies being dependable to offer and seek information, without delays in relaying or getting information that could compromise patient care, recheck, and validate

Challenges to effective communication include language barriers, distractions such emergency, distance, and personalities that are difficult to communicate with, heavy workload and varying communication styles, and disagreement which may disrupt flow of information. Lack of verification and acknowledgement of received information and transitions in care of

Ms. Rono, having been investigated, is now admitted for breast conserving surgery. However, the surgeon who saw her at outpatient is called for an emergency. The trainee assumes that mastectomy would be better without reference to patient or Dr. Otieno, so they perform mas-

This scenario is common where there is no clear and effective communication. A number of tools have been developed for communication in varying scenarios. Effective teams are led by

systems, it will also lead to inconsistencies in the utilization of the system [37].

information [37].

**Figure 1.** Multiple team systems.

46 Vignettes in Patient Safety - Volume 4

**3.1. Case scenario**

patient can lead to communication breakdown [37].

tectomy instead of breast conserving surgery.

It is post-mastectomy day one for Ms. Rono; her drainage tube is not working well and the mastectomy site is full because of hematoma/seroma. The patient is in pain. The nurse is notified and so she decides to escalate the problem to the surgeon. She would identify herself by her name and state that Ms. Rono has a postmastectomy hematoma; she is a patient who had right sided mastectomy the day before, and currently her drain is not working well. She has examined and found the mastectomy site to be swollen and warm and suggests that another drain would help.

While doing this, the nurse and the doctor can use check-back or closed-loop systems that ensure that the message passed by the nurse is repeated to her by Dr. Otieno and she acknowledges and ascertains the message being passed; this helps in verification of the message. In situation where, for example, Ms. Rono has bled a lot and requires the resuscitation team, the nurse would have to use call-out, which means sending the message to all the members of the team at once. It is a method of sending critical information during an emergent event. The information is used to prepare the team members to anticipate what the situation is and how to act. Usually the team leader may distribute tasks that need to be performed to specific members; the check-back confirms that the team member has received and understood the message [37].

Most of the hospital staff works in shifts, and it has been noted that most of the adverse events occur during this change-over period. If the nurse in the morning had noticed the hematoma and because of distraction had not called and fails to notify his or her colleagues in the next shift, that patient may not be attended to until she requires resuscitation, if the bleeding remains active. To avoid such events, there is a tool used for handoffs, which aims to provide accurate information about a patient's care, treatment and services, current condition, and any recent or anticipated changes. The information communicated during a handoff must be accurate to meet patient safety goals [37].

One of the most effective communication tools that surgical teams have ever used that have reduced medical errors in operative room is the WHO operative checklist. It helps the team of the surgeon, anesthesia, scrub nurse, circulating nurse, and technicians communicate smoothly. Surgical team leaders share information proactively with their teams, using components of the safe surgical checklist including briefings, huddles, and debriefings. They will initiate and ensure that the time-outs are run. They can delegate or defer to experts and currently there is enough information to say that surgical teams who do not use surgical checklist endanger the patient. When it was introduced, the recorded reduction in mortality was 47% and reduction in complication was 35%. Surgical teams who use these skills capture errors before they can cause patient harm and it is the responsibility of the surgeon to ensure that all

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 49

The entire surgical team introduce themselves and their roles before the incision and agree on the surgical procedure, surgical site and preoperative prophylaxis. During the first briefing, the surgeon shares the surgical plan, possible difficulties, expected duration, anticipated blood loss, and implants or equipment needed. The anesthesiologists also share their plan, their airway concerns including equipment. The nursing team shares sterility of equipment issues and other concerns they may have. Debriefing is sign out part that ensures the counts are fine, records are kept of the procedure, specimen is labeled, and a review of what was done in terms of roles, what went well, what should we change, and what can improve. Any error avoided, did we ask or offer assistance and was situation awareness maintained, was

Within the checklist is included one of the tools that not only help with safety but also quality improvement and that are debriefing (**Table 1**). It should be done by the clinical team leader when everyone is still in the room, after sponge count, specimen is labeled, and procedure identification is done. The surgeon should facilitate the discussion by asking some of the questions above; they could also recap the situation, background, nay key event that occurs

Given the nature of surgery is that of teamwork, it is inevitable that conflict will arise because of differences in clinical knowledge, work approaches, values, opinions, or personality. Conflict resolution is key to delivering safe quality surgical care. Skills for resolving conflict will enhance team effectiveness and improve their outcomes. An effective leader will not allow interpersonal or irrelevant issues to negatively affect the team. They should not avoid but acknowledge and assist the team members to manage conflict with two challenges—CUS

DESC challenge is a constructive approach of managing and resolving conflict that involves describing the specific situation, expressing your concern about the action, and suggesting alternatives while stating the consequences of the actions. The effectiveness of this method could be maximized by having timely discussion, in a private place, framing the problem in one's own experience and working for the right of the patient, using "I", avoiding blame

CUS challenge is that for being concerned or need clarity, I am uncomfortable, this is safety issues (I am scared STOP!). These two challenges are useful in raising concern about safety [37].

games, focus on what is right not on who is right, critiquing, and not criticizing [37].

the elements of the checklist are performed as intended [39–41].

communication clear [40].

and DESC [37].

and summarize the lessons learnt.

Handoff needs to include transfer of both accountability and responsibility, the person assuming responsibility must be aware of what they are assuming, and the person handing over is responsible until both parties are aware of the transfer. It is the responsibility of the person transferring responsibility to clear up any uncertainty and ambiguity. While it is important to write and document the issues about the patients, it is reckless to assume that the person obtaining responsibility will read or understand written or nonverbal communication. Use of checkbacks also does help because it is until the receiver has acknowledged that the handoff is understood and accepted that the responsibility is relinquished. It may also be an opportunity to review the patient with new thoughts both for quality and safety, review the certainty of diagnosis, and patient response to treatment, and recent changes either in plans or response and other contingencies can be reviewed. Handoffs ensure continuity of care for the patient and hence increase chances of better outcome for the patient [37].

One of the tools used is I PASS the BATON mnemonic, which means


It is important for the person taking over to verbally question, confirm, and challenge the assumptions of those who take care of the patient at this point. The clinical team leadership for the surgical patient is always the surgeon. The surgeon is therefore expected to model appropriate behavior, share information proactively, defer to expertise or delegate as appropriate, use resources appropriately, provide feedback and coach those he leads, assist team members to manage conflicts, and always act in patient's interest [37].

One of the most effective communication tools that surgical teams have ever used that have reduced medical errors in operative room is the WHO operative checklist. It helps the team of the surgeon, anesthesia, scrub nurse, circulating nurse, and technicians communicate smoothly. Surgical team leaders share information proactively with their teams, using components of the safe surgical checklist including briefings, huddles, and debriefings. They will initiate and ensure that the time-outs are run. They can delegate or defer to experts and currently there is enough information to say that surgical teams who do not use surgical checklist endanger the patient. When it was introduced, the recorded reduction in mortality was 47% and reduction in complication was 35%. Surgical teams who use these skills capture errors before they can cause patient harm and it is the responsibility of the surgeon to ensure that all the elements of the checklist are performed as intended [39–41].

accurate information about a patient's care, treatment and services, current condition, and any recent or anticipated changes. The information communicated during a handoff must be

Handoff needs to include transfer of both accountability and responsibility, the person assuming responsibility must be aware of what they are assuming, and the person handing over is responsible until both parties are aware of the transfer. It is the responsibility of the person transferring responsibility to clear up any uncertainty and ambiguity. While it is important to write and document the issues about the patients, it is reckless to assume that the person obtaining responsibility will read or understand written or nonverbal communication. Use of checkbacks also does help because it is until the receiver has acknowledged that the handoff is understood and accepted that the responsibility is relinquished. It may also be an opportunity to review the patient with new thoughts both for quality and safety, review the certainty of diagnosis, and patient response to treatment, and recent changes either in plans or response and other contingencies can be reviewed. Handoffs ensure continuity of care for the patient and hence increase chances of better outcome for

• P—They then give a summary of the patient illness including name, identifiers, age, sex,

• A—They detail the assessment, like chief complaint, vital signs, symptoms, and diagnosis • S—The situation the patient is in currently including code status, level of uncertainty,

• S—Safety concerns—recent lab values and reports of concern, socio-economic factors,

• Background—Comorbidities, previous episodes, current medications, and family history • Action—What actions were taken or are required? Provide brief rationale for the actions

• Ownership—Who is responsible (nurse/doctor/team)? Includes patient/family responsibilities • Next—What will happen next? Anticipated changes? What is the plan? Are there contin-

It is important for the person taking over to verbally question, confirm, and challenge the assumptions of those who take care of the patient at this point. The clinical team leadership for the surgical patient is always the surgeon. The surgeon is therefore expected to model appropriate behavior, share information proactively, defer to expertise or delegate as appropriate, use resources appropriately, provide feedback and coach those he leads, assist team

• Timing—Level of urgency and explicit timing and prioritization of actions

members to manage conflicts, and always act in patient's interest [37].

One of the tools used is I PASS the BATON mnemonic, which means

• I—The person handing over introduces themselves

recent changes, and response to treatment.

accurate to meet patient safety goals [37].

48 Vignettes in Patient Safety - Volume 4

the patient [37].

and location.

alerts, and allergies

gency plans.

The entire surgical team introduce themselves and their roles before the incision and agree on the surgical procedure, surgical site and preoperative prophylaxis. During the first briefing, the surgeon shares the surgical plan, possible difficulties, expected duration, anticipated blood loss, and implants or equipment needed. The anesthesiologists also share their plan, their airway concerns including equipment. The nursing team shares sterility of equipment issues and other concerns they may have. Debriefing is sign out part that ensures the counts are fine, records are kept of the procedure, specimen is labeled, and a review of what was done in terms of roles, what went well, what should we change, and what can improve. Any error avoided, did we ask or offer assistance and was situation awareness maintained, was communication clear [40].

Within the checklist is included one of the tools that not only help with safety but also quality improvement and that are debriefing (**Table 1**). It should be done by the clinical team leader when everyone is still in the room, after sponge count, specimen is labeled, and procedure identification is done. The surgeon should facilitate the discussion by asking some of the questions above; they could also recap the situation, background, nay key event that occurs and summarize the lessons learnt.

Given the nature of surgery is that of teamwork, it is inevitable that conflict will arise because of differences in clinical knowledge, work approaches, values, opinions, or personality. Conflict resolution is key to delivering safe quality surgical care. Skills for resolving conflict will enhance team effectiveness and improve their outcomes. An effective leader will not allow interpersonal or irrelevant issues to negatively affect the team. They should not avoid but acknowledge and assist the team members to manage conflict with two challenges—CUS and DESC [37].

DESC challenge is a constructive approach of managing and resolving conflict that involves describing the specific situation, expressing your concern about the action, and suggesting alternatives while stating the consequences of the actions. The effectiveness of this method could be maximized by having timely discussion, in a private place, framing the problem in one's own experience and working for the right of the patient, using "I", avoiding blame games, focus on what is right not on who is right, critiquing, and not criticizing [37].

CUS challenge is that for being concerned or need clarity, I am uncomfortable, this is safety issues (I am scared STOP!). These two challenges are useful in raising concern about safety [37].


There are other ways of managing conflict that has not been found to improve patient outcomes. These include compromise where both parties settle for less, avoidance where the issue is sidestepped or ignored altogether, accommodation or deference where the focus on preserving the relationship and not the patient interest override, or dominance where the higher status member wins or whoever yells the loudest. When the surgeon words belittle or intimidate members, it inhibits willingness to speak up and hence the surgeon must be will-

Communication in Surgery for Patient Safety http://dx.doi.org/10.5772/intechopen.79740 51

For medicine to be healing, communication with patient and other healthcare workers must be effective and efficient. The traditional models of communications in principle and theory are changing to include consideration for the global nature of the practice of medicine. New models and tools for better communication with colleagues, patients, and their relatives have been developed. Research has indicated that those who use these tools consistently have not only gained clarity in their communication but they improve physician-patient relationship and outcomes as well. Cultural considerations and modifications of models to fit international communication have led to the need of cultural competency in clinical practice. All these efforts are employed to ensure that consideration is given to the patient and outcomes in whatever context they may be. In communication, there can be misunderstanding; these must be solved speedily and in a way that is respectful to both party's perspectives so that the main interest remains the good of the patient.

ing to listen, follow ad model effective communication, and be the role model [37].

I acknowledge the contribution of my colleagues, Dr. Okutoyi and Prof Otieno.

and Frederick C. Otieno3

\*, Lydia Okutoyi2

1 Department of Surgery, University of Nairobi, Nairobi, Kenya

2 Department of Quality and Patient Safety, Kenyatta National Hospital, Kenya

\*Address all correspondence to: danielojuka@gmail.com

3 School of Medicine, University of Nairobi, Kenya

**4. Conclusion**

**Acknowledgements**

**Conflict of interest**

None to declare.

**Author details**

Daniel Kinyuru Ojuka1

**Table 1.** WHO safety checklist.

access and fluid available

Everyone in the team should be made aware that it is their responsibility to assertively raise their voice at least two times to ensure they are heard, that the member being challenged must acknowledge, and that if the outcome is not acceptable, a stronger action should be taken with the supervisor and that there should be stop the line in issues about safety including cessation of the process. While conflicts are common, that about 40% of the leader's time is spend on this, solving is critical to becoming productive and increase possibility of satisfaction of the physician and patient [37].

There are other ways of managing conflict that has not been found to improve patient outcomes. These include compromise where both parties settle for less, avoidance where the issue is sidestepped or ignored altogether, accommodation or deference where the focus on preserving the relationship and not the patient interest override, or dominance where the higher status member wins or whoever yells the loudest. When the surgeon words belittle or intimidate members, it inhibits willingness to speak up and hence the surgeon must be willing to listen, follow ad model effective communication, and be the role model [37].
