Barriers and enablers to effective interprofessional teamwork in the operating room: A qualitative study using the Theoretical Domains Framework

Background Effective teamwork is critical for safe, high-quality care in the operating room (OR); however, teamwork interventions have not consistently resulted in the expected gains for patient safety or surgical culture. In order to optimize OR teamwork in a targeted and evidence-based manner, it is first necessary to conduct a comprehensive, theory-informed assessment of barriers and enablers from an interprofessional perspective. Methods This qualitative study was informed by the Theoretical Domains Framework (TDF). Volunteer, purposive and snowball sampling were conducted primarily across four sites in Ontario, Canada and continued until saturation was reached. Interviews were recorded, transcribed, and de-identified. Directed content analysis was conducted in duplicate using the TDF as the initial coding framework. Codes were then refined whereby similar codes were grouped into larger categories of meaning within each TDF domain, resulting in a list of domain-specific barriers and enablers. Results A total of 66 OR healthcare professionals participated in the study (19 Registered Nurses, two Registered Practical Nurses, 17 anaesthesiologists, 26 surgeons, two perfusionists). The most frequently identified teamwork enablers included people management, shared definition of teamwork, communication strategies, positive emotions, familiarity with team members, and alignment of teamwork with professional role. The most frequently identified teamwork barriers included others’ personalities, gender, hierarchies, resource issues, lack of knowledge of best practices for teamwork, negative emotions, conflicting norms and perceptions across professions, being unfamiliar with team members, and on-call/night shifts. Conclusions We identified key factors influencing OR teamwork from an interprofessional perspective using a theoretically informed and systematic approach. Our findings reveal important targets for future interventions and may ultimately increase their effectiveness. Specifically, achieving optimal teamwork in the OR may require a multi-level intervention that addresses individual, team and systems-level factors with particular attention to complex social and professional hierarchies.

Balance Performance of Post-Call Medical Residents

Background: Fatigue is thought of as a leading cause of iatrogenic accidents. A significant deterioration in qualitative balance function has been shown in sleep deprived individuals. Aim/Objectives: To quantify the degree to which balance is impaired by sleep deprivation (SD) in post-call medical residents. Methods: Medical residents voluntarily underwent computed dynamic posturography (CDP) before and after an on-call night, at an identical time of the day. Order of test performance was random to avoid behavioral learning. Each participant served as his or her own control. Results: Seventeen residents were enrolled (median age 32years). Average sleeping duration the night before and during the night shift was 6.5 and 1 hour, respectively. The average response times difference between alert and fatigued was 10.15 milliseconds (95% CI: 6.81-13.49 milliseconds), yielding a significantly prolonged response times from 120 milliseconds before to 130 milliseconds after the night shift ( P < .001). Comparison of additional measurements of CDP performance did not differ between test conditions. Conclusion: Medical residents are fatigued due to the effect of on-call nights. Sleep deprivation prolongs response times to vestibular stimuli. This finding probably has an effect on execution of manual skills and may reflect a more generalized slowing of responses and overall performance impairment. Significance: The vestibular system is susceptible to SD.

A systematic review of burnout and its relation to work-life balance and scheduling among United States physicians

Physician burnout has increasingly been recognized as a multifactorial issue leading to detrimental outcomes for both the physician and patients being treated. Burnout is defined as “a pathological syndrome in which emotional depletion and maladaptive detachment develop in response to prolonged occupational stress”. It has been proven that poor work-life balance (WBL), a state in which personal and professional life are in a state of imbalance, is connected to burnout. Upwards of 61% of all U.S. physicians are dissatisfied with their WBL. Burnout rates among physicians are correlated with frequency of work-home conflicts leading to greater dissatisfaction of their WLB. With the prevalence of burnout among US physicians ranging between 34-76%, addressing modifiable causes such as optimizing WLB should be a priority for administrators. In this systematic review, we explore the importance of creating schedules that prioritize protecting physicians’ WLB as a means to decrease burnout and the associated sequelae including medical errors, alcohol abuse, and depression. After identifying 202 studies through PubMed; data from 21 articles published between 2011-2017 were analyzed. We found that schedules that emphasize the following were protective of physician WBL: <70-hour work week goals, a maximum of one on-call night per five consecutive days, providing physicians with schedule information one month in advance, limiting the consecutive work days to five and providing vacation time. As the importance of mental health, and wellness within the health care setting are being regarded as a cause of concern, it is apparent that positive changes need to be made.

Life on the wards

This chapter discusses life on the wards. It includes the medical team, the multidisciplinary team, daily ward duties, ward rounds, being on-call, night shifts, writing and common symbols in the notes, anatomical terms and planes, discharge summaries (TTOs/TTAs), fitness to work notes, referrals, referral letters, investigation requests, radiology, common ward dilemmas, pain, thinking about death, palliative care, the dying patient, death, nutrition, nutritional requirements, difficult patients, aggression and violence, needle-stick injuries, surgery, pre-op assessment, bowel preparation, surgical terminology, preparing in-patients for surgery, booking theatre lists, surgical instruments, the operating theatre, post-op care, post-op problems, wound management, common elective operations, and stomas.

Salivary alpha amylase in on-call from home fire and emergency service personnel

The effect of working on-call from home on the sympatho-adrenal medullary system activity is currently unknown. This study had two aims, Aim 1: examine salivary alpha amylase awakening response (AAR) and diurnal salivary alpha amylase (sAA) profile in fire and emergency service workers who operate on-call from home following a night on-call with a call (NIGHT-CALL), a night on-call without a call (NO-CALL) and an off-call night (OFF-CALL), and Aim 2: explore whether there was an anticipatory effect of working on-call from home (ON) compared to when there was an off-call (OFF) on the diurnal sAA profile. Participants wore activity monitors, completed sleep and work diaries and collected seven saliva samples a day for one week. AAR area under the curve with respect to ground (AUCG), AAR area under the curve with respect to increase (AUCI), AAR reactivity, diurnal sAA slope, diurnal sAA AUCG and mean 12-h sAA concentrations were calculated. Separate generalised estimating equation models were constructed for each variable of interest for each aim. For Aim 1, there were no differences between NIGHT-CALL or NO-CALL and OFF-CALL for any response variable. For Aim 2, there was no difference between any response variable of interest when ON the following night compared to when OFF the following night (n = 14). These findings suggest that there is no effect of working on-call from home on sAA, but should be interpreted with caution, as overnight data were not collected. Future research, using overnight heart rate monitoring, could help confirm these findings.

Perception of Fatigue Among Surgeons During Night Shifts

It is well known that sleep deprivation induces fatigue and that fatigue induces impaired cognition. Studies have demonstrated that long work hours, restricted sleep, time pressure and high demands may cause impaired performance in physicians. Some studies have shown through laparoscopic simulation that surgeons, when deprived of sleep, take longer to perform the procedure, make more unnecessary movements with their instruments and significantly more mistakes. Surgeons with an opportunity for sleep of less than 6 hours on the previous on-call night shift had an 83% increase in risk of postoperative complications when working the following day.