- uncertainty
the sense of not knowing what will happen next.
- situation awareness
the kind of awareness that a person may have of their surrounding context, including people, processes and objects.
Increasingly, health care is delivered by teams with members from different specialties. Each team member may bring a unique perspective, skill set and expertise. Each team member has a moral and ethical responsibility to advocate the best outcomes for the patient using their individual expertise and experience. Too often, however, team members lack the communication skills to be effective. Their communication and agency may be impaired by rigid patterns of hierarchy and authority.
- hierarchy
different levels of power that people have in formal organisations.
This chapter explores the challenges of communication in critical situations. It presents an example of care provided to a severely injured motor vehicle accident patient, and of an intraoperative surgical complication. We discuss the technique of graded assertiveness to facilitate communication that encounters different kinds of hierarchical constraints.
- graded assertiveness
assertiveness that becomes stronger and more insistent depending on others’ responses.
The chapter claims that graded assertiveness should be seen as a communicative act that all team members have a responsibility to be able to undertake. Indeed, graded assertiveness is presented as critical to enhancing any leader’s situation awareness.
Introduction
Health practitioners are required to make a multitude of decisions throughout the day. Each decision requires a combination of knowledge, clinical experience, and awareness of the unique clinical context for that patient. ‘Situation awareness’ is a concept that refers to a person’s or team’s understanding of the past, present, and potential futures of a complex situation.
Unlike formal knowledge or expert skills, situation awareness requires ongoing investment to maintain awareness and understanding of a complex situation. Think about driving a car – the skills and knowledge needed to drive are acquired early in your driving experience, but each time you drive you are constantly scanning the mirrors and looking out the windows to maintain your situation awareness.
When there is a rapidly evolving clinical scenario, maintaining situation awareness becomes a major task for team leaders. Any decision a practitioner makes can only be as good as the information upon which it is based. In a team environment, all members contribute information, and this creates ‘group situation awareness’. Effective team leaders establish a shared and explicit expectation about team relationships and communication. This ensures that team members will be effective. Effective team members are better at communicating changes in the clinical status of a patient (or other pertinent environmental information) when it matters (Gillespie et al., 2013; Wacker & Kolbe, 2014). This effectiveness manifests as bidirectional communication: it ensures that care is coordinated and that decisions are based on the most up-to-date and accurate information. Too often, however, hierarchy creates communication barriers.
‘Speaking up’
Because modern health care is becoming increasingly complex, it needs to be delivered by collaborative and multidisciplinary teams. This means that the quality of how teams function has a significant impact upon the quality and safety of clinical care delivered. Despite our increasing appreciation that all team members play a role in creating safe and high-quality care, there is still reluctance from many practitioners to speak up; even when they do so, sometimes they aren’t heard. Admittedly, emergency departments and operating theatres are noisy and highly interruptive environments (Coiera et al., 2002; Grundeiger & Sanderson, 2009; Rivera-Rodriguez & Karsh, 2010; Weigl et al., 2011). But not hearing another team member may be more commonly due to power differentials in the healthcare team than to circumstantial noise. Indeed, the severity of this problem of not hearing another person is likely to be proportional to the importance accorded to people’s status in the hierarchy, or the ‘hierarchy gradient’ that prevails in the organisation.
Organisations that have a steep hierarchy gradient tend to display rigid modes of communication and inflexible decision-making. For example, imagine a ward nurse has a question for the medical team about her patient. She speaks to the nurse in charge, who speaks to the intern, who speaks to the registrar, who speaks to the consultant. Decisions are communicated in an equally linear and hierarchical way. This kind of hierarchical approach to communication and decision-making is often evident in the operating theatre, an environment where communication frequently ‘fails’ (Lingard et al., 2004; McDonald, Waring & Harrison, 2005).
In organisations that have a less hierarchical approach to communicating and decision-making (that is, a low hierarchy gradient), there are fewer practical, psychological and physical barriers between front-line workers and senior staff. In a ward with a low hierarchy gradient, the same ward nurse would feel comfortable asking her question or communicating her perspective to the consultant directly. Ward practice would routinely accommodate such communication, and there would be fewer psychological barriers (such as fears) and physical barriers (such as closed office doors or junior doctors surrounding the senior consultant) obstructing such communication.
That said, a disadvantage of a low hierarchy gradient can be confusion about who is responsible for taking decisions and a degree of disorganisation during non-routine or dynamic situations such as emergencies. Emergencies do not leave adequate opportunity for dynamically negotiating decision-making roles. Effective teamwork during emergency situations requires clear pre-established leadership roles and lines of authority (Klein, 1998). By the same token, if these roles and lines of authority become too rigid, they will diminish the dynamics of team member’s responses, and a degree of flexibility is always needed to adequately deal with emerging circumstances. Before going into greater detail about these issues, let us consider practice example 20.1.
This dialogue is between members of a trauma team managing a patient with complex needs following a motor vehicle accident.
‘John Doe’ is a male in his sixties. He was a front seat passenger in a sedan that was struck by another car at 80 km/hour, the impact on the passenger-side door. He was trapped in the vehicle for about 30 minutes before emergency services could extract him. On arrival at the hospital he was met by the trauma team. His clinical condition was extremely unstable. He required ongoing blood transfusion to maintain a low normal blood pressure. An ultrasound scan of his abdomen identified free fluid (suggestive of internal bleeding). Discussion occurred between anaesthetist and surgeon about the most appropriate place for this patient to go – the operating theatre or the angiography suite.
ANAESTHETIST: So what’s the plan?
SURGEON: Let’s get this guy into the scanner and work out what’s going on. Probably need to embolise his spleen.
ANAESTHETIST: Look, I’m needing to pump in a fair bit of blood at the moment. Should we just take him to theatre?
SURGEON: Why should he go to theatre?
ANAESTHETIST: I think he’s quite unstable. Don’t we take unstable patients to theatre first?
SURGEON: I don’t think he’s unstable. I don’t really believe those numbers. We are taking him to CT [computed tomography].
ANAESTHETIST: [Under his breath] What do you classify as unstable then? Full arrest? There’s a hospital protocol for this.
The patient is transferred to CT and subsequently to angiography for embolisation of a ruptured spleen. Before the embolisation procedure can begin the patient has a cardiac arrest.
SURGEON: [Swears] What’s going on with this guy? There must be something we are missing.
ANAESTHETIST: No. He’s just bleeding to death from his spleen. Now can we take him up to theatre?
SURGEON: If we get him back, then yes.
Analysis and reflection
The practice example demonstrates a clear disconnect between the surgeon’s and the anaesthetist’s clinical priorities. The surgeon failed to incorporate the anaesthetist’s assessment into his own planning, while at the same time the anaesthetist did not make sufficient effort to communicate his impression of the clinical situation.
The correct course of action seems clear in hindsight, but is often not obvious during an uncertain and chaotic trauma scenario. Usually there is little information available about the patient or their injuries upon their arrival to the emergency department. Each clinician in this context is required to make the best of a bad situation.
How could this have been done better? First, in any uncertain situation it is paramount for the team leader to make the best use of the resources available. In this example the surgeon, as team leader, should have placed greater weight on the concerns of the anaesthetist about the patient’s instability. Rather than being dismissive of another’s concerns, further enquiry (‘Why do you think he is unstable?’) would have allowed adequate exploration of the issues and a more informed decision about the most appropriate treatment location. There was also the opportunity to involve the team in the surgeon’s thinking. Explaining the requirements for the CT scan and negotiating a time for reassessment would have helped maintain a cohesive team and enhanced group situational awareness. For example, questions that could have been asked are: ‘Do you think he would cope with a 15-minute CT scan? At the end of the scan we can reassess before going further.’
While the anaesthetist in this scenario identified a clinical concern, he was a poor advocate for the patient, and a poor team member. Rather than muttering under his breath when his concerns were not appreciated at the first communication, there was an opportunity to use hints, probes and the like to ensure that their impression was incorporated into the clinical management. This is referred to as ‘graded assertiveness’. Examples might be: ‘I am very concerned the patient may arrest soon if we don’t take them to theatre’; ‘I think this patient meets criteria for urgent surgery. Is there a reason you don’t want to operate?’; ‘This patient meets the criteria for theatre based on the hospital policy. I am taking the patient to theatre now.’
Muttering concerns or disagreement is an example of destructive conflict and undermines the team leader to the entire team. Such comments are often made to more junior staff and set a very poor example for a highly functioning team. It is not surprising that other trauma team members didn’t offer relevant opinions to help with decision-making.
- conflict
feelings of dislike, disagreement or animosity between people.
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