J. Bryan Sexton

1
Roles, Status and Face in the Medical Operating
Room Human Factors at Work
J. Bryan Sexton The University of Texas at
AustinDepartment of Psychology Human Factors
Research Project Technical Report
99-3 Presentation given at the Grand Rounds of
Albany Medical College Albany, New York April 8,
1999 Funded by grants from the Gottlieb-Daimler
and Karl-Benz Foundation (18-04/99, Robert
Helmreich - PI) and the Swiss National Science
Foundation (3200-040429, Hans Schaefer - PI)
2
Primary Factors for Hull Loss Accidents Worldwide
Commercial Jet Fleet
Percentage of accidents
80
60
Last 10 Years
40
20
0
Flightcrew
Airplane
Maintenance
Weather
Airport/ATC
Other
Last 10 Years
68.9
13.1
3.3
3.3
7.4
4.1
Data from Boeing Aircraft Company Excludes
military sabotage
3
Human Factors are a contributing factor in 70 of
accidents across domains

• Aviation
• Maritime
• Nuclear Petrochemical Operations
• 70-80 of Anesthetic Surgical mishaps involve
  human error
• Chopra et al. (1992)
• Kumar et al. (1988)
• Williamson et al. (1993)
• Schaefer Scheidegger (1993)

4
Common Human Factors Problems

• Leadership
• Communication
• Decision-Making
• Situational Awareness
• Teamwork
• Best way to address these issues is through the
  initial team briefing

5
Briefing content predicts performance

• Two critical components to effective briefing
• Technical
• cover the specifics of the surgery or anesthesia,
  PAX condition, expected contingencies, etc
• Interpersonal
• lay the groundwork for subsequent teamwork
• Briefings which address only one component fail
  to predict subsequent performance

6
Briefing Content

• 2 critical components display competence while
  disavowing perfection (Face)
• Atmosphere for open communications is established
  (dont let me do anything stupid)
• Expectations are verbalized (sets norms for
  behavior)
• This can be done in a matter of seconds!
• Ginnett (1987)
• Hines (1998)

7
Briefing Content

• 2 critical components display competence while
  disavowing perfection (Face)
• Atmosphere for open communications is established
  (dont let me do anything stupid)
• Expectations are verbalized (sets norms for
  behavior)
• This can be done in a matter of seconds!
• Ginnett (1987)
• Hines (1998)

8
Face

• Face is the public self image we wish to claim
  for ourselves - the way we would like others to
  think of us
• Face is a universal in interpersonal interaction
• The traffic rules of interpersonal interaction
  (gaining, losing, and saving face)
• Cant lose face alone, it is public, not private
• Attitudes about face predict performance in
  aviation, both on the line and in simulators
• Face has been linked to commercial aviation
  accidents where the first officer failed to
  speak-up

9
Controlled Flight Into choo-choo Terrain
10
Salience of Face in the OR

• High expectations of society for medical
  personnel heightens face (Mistakes are not
  tolerated)
• Threat of malpractice makes it illegal to be
  wrong
• Personal reputation
• Nod Grin Response we often feign comprehension
  in our interactions to avoid appearing
  incompetent or less than adequately informed -
  Especially true in hierarchical and multicultural
  interactions

11
Examples of Face Related Attitudes from Aviation

• Pilots should be aware of and sensitive to the
  personal problems of other crew members (Superior
  Agree)
• Captains should employ the same style of
  management in all situations and with all
  crewmembers (Superior Disagree)
• Captains should encourage their First Officers to
  question procedures during normal flight
  operations and in emergencies (Superior Agree)

12
Two types of face in the OR

• Competence Face The desire to be seen as a
  person of ability
• Fellowship Face The desire to be seen as a
  worthy social interaction partner
• Both types are consistently rated as an important
  issue across hospitals and across positions
  within hospitals

13
Examples of Competence Face Attitudes from
Medicine

• I am ashamed when I make a mistake in front of
  other team members
• A good reputation in the OR is important to me
• It bothers me when others do not respect my
  professional capabilities

14
Examples of Fellowship Face Attitudes from
Medicine

• We should be aware of and sensitive to the
  personal problems of other OR team members
• I enjoy working as part of a team
• Maintaining good interpersonal relationships with
  all other OR personnel is important to me

15
Importance of Face Across Hospitals
Disagree Strongly to Agree Strongly
16
Importance of Face Across OR Positions
Disagree Strongly to Agree Strongly
17
When is face most salient?When there are
differences in status!
18
Status

• In an investigation conducted by Harper, Kidera
  Cullen (1971) at a major air carrier, captains
  feigned subtle incapacitation at a predetermined
  point during final approach in simulator trails
  characterized by poor weather and visibility.
  Approximately 25 of these simulated flights hit
  the ground, because, for some reason, the first
  officer did not take control.
• We dont want to look stupid (assumption is - of
  course the CA is not going to fly the plane right
  into the ground)

19
What are the effects of differences in status on
group behavior?

• In task-performing teams, team members are rarely
  equal in status, and leadership plays an
  important part of effective team functioning
• Higher status individuals have more influence
  over team decisions, and are less prone to follow
  norms
• Status differences establish lines of authority
  and control and also provide a means of rewarding
  and encouraging behavior that benefits the group
• Different roles are usually associated with
  different degrees of status (the following was a
  study to explore this idea further)

20
Who is Who in the OR?

• 27 ORs were surveyed over a 3 day period
• Every team member was asked to rate
• Communication during last surgery (1low to
  10high)
• Team Atmosphere during last surgery (1low to
  10high)
• Then give the names of each team member from
  memory (first last)
• Anesthesia Attending _______ __________
• Anesthesia Resident _______ __________
• Surgical Attending _______ __________
• Surgical Nurse, etc...

21
Who is Who in the OR?

• Atmosphere was moderately correlated (.4 - .6)
  with target scores, i.e. if an anesthesia
  resident rated atmosphere as a 2 out of 10, very
  few people tended to know that anesthetists
  name. Furthermore, that anesthetist knew very
  few names of other OR team members
• Regression analyses on these data allow you to
  predict Anesthesia Resident atmosphere and
  communication scores based on either the of
  names they know or the percent of others who knew
  their names (clear relationship between
  self-report and survey of the other team
  members).
• Most people knew the first name of the scrub
  nurse, and the last name of the operating surgeon.

22
Knowledge of name relates to status
Percent of team who knows target name
Target
23
Percent of Names known by the Perceiver
60
50
40
Percent of names known
30
20
10
0
A Res
A Attndg
S Res
S Attndg
S Nurse
Orderly
Perceiver
Perciever 1st name
Perciever 2nd name
17
24
Who is Who in the OR?

• In sum, team atmosphere, communication, and name
  knowledge are all related it might be a good
  idea to introduce yourself the next time you see
  a new face

25
Perceptions of the quality of Teamwork and
Cooperation / Communication with other O.R.
Personnel (by status)

• In a survey of 10 hospitals, we found significant
  differences in perceptions of teamwork across
  O.R. positions
• Surgeons tend to perceive teamwork (across the
  ether screen) as more than adequate and
  anesthesiologists tend to perceive teamwork
  (across the ether screen) as less than adequate.
  
• You commonly hear Hey Anesthesia! but seldom
  will you hear Hey Surgery
• Further discrepancies can be found between
  surgical nurses and surgical attendings, and also
  between anesthesia residents and anesthesia
  attendings

26
Teamwork as a 2-way Street Teamwork Rating
Discrepancies 1 very low 5 very high
Teamwork rating
3 Adequate
27
Teamwork as a 2-way Street Teamwork Ratings
Anesthesia and Surgical personnel give each
other 1 very low 5 very high
Teamwork rating
3 Adequate
28
Conflict between anesthesia and surgery was
observable in 10 of operations - 80 of that
conflict went unresolved!
In the commercial aviation cockpit, you also see
conflict 10 of the time, but there it is
resolved in 80 of the flights
29

• In other words, data from surveys at 10
  hospitals, behavioral observations of OR teams,
  and the Who is Who in the OR study each provide
  evidence to the same point the intersection
  between anesthesia and surgery is a domain where
  teamwork falters.

30
Briefings in the Operating Room
31
Longitudinal Effects of HF Training on
Performance in Line Operations
Avg rating. Scale1poor...5excellent
3.6
3.4
3.2
3
2.8
Briefings
Comm/
Decisions
Technical
Prep/
Prof
Planning
Pre-HF Line Audit
Year 1
Year 2
Year 3
32
Face and Status Ramifications for training

• Briefing more effectively
• Teaching more thoroughly
• Smoother running workplace, especially between
  disciplines (anesthesia and surgery)

33
Relative expenditures for anesthesia equipment
and staff training
Thousands
Helmreich Schaefer (1994)
34
Take-Home Points

• Majority of accidents/incidents involve human
  interaction.
• The interface between surgery and anesthesia
  offers ample opportunity for breakdowns in
  communication and conflict (usually unresolved).
• Focus on the interpersonal aspects of working in
  the OR can improve patient safety and job
  satisfaction
• Explicitly open the channels of communication
  through Briefing
• Beware of the Nod Grin response
• Introduce yourself to new team members
• Great strides have been made in Anesthesia

35
Please feel free to visit our website for more
information
www.psy.utexas.edu/psy/helmreich/nasaut.htm