Leadership and teamwork in anesthesia – Making use of human factors to improve clinical performance

Navigating the complex dynamics of anesthesiologists' professional identity formation in the context of their specialty training program: a phenomenographic perspective

BACKGROUND

A specialty training program is crucial for shaping future specialist doctors, imparting clinical knowledge and skills, and fostering a robust professional identity. This study investigates how anesthesiologists develop their professional identity while navigating unique challenges specific to their specialty. The formation of professional identity in anesthesiology significantly influences doctors' well-being, teamwork, and ultimately patient care, making it a crucial aspect of anesthesiology education. Utilizing a phenomenographic approach, the research explores the learners' personal experiences and perspectives of professional identity formation in their specialty training programs, providing valuable insights for enhancing future anesthetic educational programs.

METHOD

The data for this phenomenographic study were collected through semi-structured interviews with anesthesiology trainees and specialists, guided by open-ended questions. The interviews were conducted at a Swedish university hospital, and participant selection used purposive sampling, providing rich and diverse data for analysis after 15 interviews. Iterative analysis followed the seven-step phenomenographic approach. The research team, comprising qualitative research and anesthesiology education experts, ensured result validity through regular review, discussion, and reflective practices.

RESULTS

The study reveals three fundamental dimensions: 'Knowledge of Subject Matter,' 'Knowledge of Human Relations,' and 'Knowledge of Affect.' These dimensions offer insights into how anesthesiologists comprehend anesthesiology as a profession, navigate interactions with colleagues and patients, and interpret emotional experiences in anesthesiology practice - all crucial elements in the formation of professional identity. The findings could be synthesized and further described by three conceptions: The Outcome-Driven Learner, the Emerging Collaborator, and the Self-Directed Caregiver.

CONCLUSION

The study uncovers differing learner understandings in the development of anesthesiologists' professional identity. Varying priorities, values, and role interpretations highlight the shortcomings of a generic, one-size-fits-all educational strategy. By acknowledging and integrating these nuanced learner perspectives, as elucidated in detail in this study, the future of anesthesia education can be improved. This will necessitate a holistic approach, intertwining both natural sciences and humanities studies, focus on tacit knowledge, and flexible teaching strategies, to guarantee thorough professional development, lifelong learning, and resilience.

Anaesthesia cart standardisation expedites supply retrieval: A simulation study with patient safety implications

BACKGROUND

Anaesthesia providers often work at a variety of perioperative and procedural locations. However, the layout of anaesthesia supplies and equipment is often inconsistent from operating theatre to operating theatre. This lack of standardisation may create delays in identification and retrieval of supplies. The primary goal of this study was to compare the duration of time required by anaesthesia providers to identify and retrieve a list of anaesthesia supplies prior to and after standardisation of the location for anaesthesia supplies.

METHODS

In this observational simulation study, a pre-set list of ten items that may be rapidly needed when caring for patients was created. Volunteer anaesthesia providers were then timed retrieving these in two different operating theatres before and after anaesthesia cart standardisation. Cumulative time to retrieve all items was recorded in seconds. Participants were evaluated regarding mean time to compete the task before and after supply standardisation. Paired t-test were used to assess mean time to retrieve the ten items both before and after standardisation and between the two operating theatre locations. Providers were also evaluated on their familiarity with the operating theatre location, and this was assessed by chi-square tests of homogeneity. Multivariable generalised linear modelling was used to evaluate the impact of covariables on the change in time.

RESULTS

Data from 18 anaesthesia providers was collected. Mean (95% confidence interval) time in seconds to retrieve items was decreased by 45% after supply standardisation (105.3 [88.6, 121.9 vs 57.1 [50.8, 63.5]; p < 0.001) with a mean (95% confidence interval) reduction of 48.1 seconds (30.6, 65.6; p < 0.001). Providers who worked primarily at that location also had faster times to complete the task. In a multivariable regression model that considered both the provider's familiarity with the location and the simulation attempt (Operating theatre 1 or Operating theatre 2), the mean time to retrieve all items remained reduced by 48.1 seconds (95% confidence interval: 31.9-64.4) after supply standardisation (p < 0.001).

CONCLUSION

Standardisation of the location for anaesthesia supplies decreased the time for on-demand item retrieval. Retrieval times were most improved after standardisation for providers in an unfamiliar area. Supply standardisation of anaesthesia carts across perioperative and procedural sites could result in more timely interventions in patient care and efficiency.

Importance of non-technical skills in anaesthesia education

Rising concern about patient safety has resulted in growing interest in non-technical skills (NTS) among anaesthesiologists. Growing evidence suggesting the use of good NTS training in patient safety in simulated as well as real-world environment made them important in medical education. Both technical skills (TS) and NTS are interdependent. Successful task performance depends on effective integration of both TS and NTS for any given situation. Development of tools for assessing the NTS of an anaesthesiologist in improving health care outcomes is challenging. Teaching, understanding and evaluating NTS among anaesthesiologists in improving health care outcomes is a domain which is supposed to be a rich seam for future studies.

Trainee doctors' experiences of learning and well-being while working in intensive care during the COVID-19 pandemic: a qualitative study using appreciative inquiry

OBJECTIVES

Concern about trainee work-related well-being has been raised in recent years and is the subject of several reviews, reports and research studies. This study aimed to understand the experiences of trainees working in a large intensive care unit during the first surge of the COVID-19 pandemic from an educational and operational perspective in order to highlight what worked and what could be improved.

DESIGN

A qualitative study using peer-to-peer semistructured interviews, developed using appreciative inquiry methodology, was conducted during July 2020. Responses were analysed using a thematic analysis technique.

SETTING

A large, tertiary intensive care unit in the UK.

PARTICIPANTS

All trainees in anaesthesia and intensive care working on the intensive care unit during the first surge were invited to participate.

RESULTS

Forty interviews were conducted and four over-arching themes were identified. These were: feeling safe and supported; physical demands; the emotional burden of caring; and a sense of fulfilment, value and personal development. Positive aspects of the organisational response to the pandemic included communication, personal protective equipment supply, team working and well-being support. Suggestions for improvement focused on rest facilities, rota patterns and hierarchies, creating opportunities for reflection and ensuring continued educational and training opportunities despite operational demands.

CONCLUSIONS

Trainees described opportunities for learning and fulfilment, as well as challenges, in working through a pandemic. Trainees described their needs and how well these were met during the pandemic. Ideas for improvement most frequently related to basic needs including safety and fatigue, but suggestions also related to supporting learning and development. The appreciative inquiry methodology of the project facilitated effective reflection on positive aspects of trainee experiences.

Becoming the temporary surgeon: A grounded theory examination of anaesthetists performing emergency front of neck access in inter-disciplinary simulation-based training

The time-critical 'can't intubate, can't oxygenate' [CICO] emergency post-induction of anaesthesia is rare, but one which, should it occur, requires Anaesthetists to perform rapid emergency front of neck access [FONA] to the trachea, restoring oxygenation, and preventing death or brain hypoxia. The UK Difficult Airway Society [DAS] has directed all Anaesthetists to be trained with surgical cricothyroidotomy [SCT] as the primary emergency FONA method, sometimes referred to as 'Cric' as a shorthand. We present a longitudinal analysis using a classical approach to Grounded Theory methodology of ten Specialist Trainee Anaesthetists' data during a 6-month training programme delivered jointly by Anaesthetists and Surgeons. We identified with a critical realist ontology and an objectivist epistemology meaning data interpretation was driven by participants' narratives and accepted as true accounts of their experience. Our theory comprises three themes: 'Identity as an Anaesthetist'; 'The Role of a Temporary Surgeon'; and 'Training to Reconcile Identities', whereby training facilitated the psychological transition from a 'bloodless Doctor' (Anaesthetist) to becoming a 'temporary Surgeon'. The training programme enabled Specialist Trainees to move between the role of control and responsibility (Identity as an Anaesthetist), through self-described 'failure' and into a role of uncertainty about one's own confidence and competence (The Role of a Temporary Surgeon), and then return to the Anaesthetist's role once the airway had been established. Understanding the complexity of an intervention and providing a better insight into the training needs of Anaesthetic trainees, via a Grounded Theory approach, allows us to evaluate training programmes against the recognised technical and non-technical needs of those being trained.

Anesthesiologists Have an Important Role in Preclinical Nurse Anesthesia Education

Anesthesiologists do not participate regularly in the preclinical portion of nurse anesthesia training programs (NAPs). This practice is predicated on a historical separation of the early educational tracks of physicians and advanced practice nurses whose professions ultimately came to occupy overlapping niches within the field of anesthesia. The state of affairs has been bolstered by territorial friction between professional organizations, and by the lack of a perceived need for anesthesiologists to become involved at an early stage of nurse anesthesia education given the large number of qualified certified registered nurse anesthesia instructors available to perform this role. Anesthesiologists, however, have significant pedagogical assets to offer NAPs, including expertise in critical analysis and decision-making skills related to perioperative adverse events. In addition, introduction of anesthesiologists into preclinical NAP education has the potential to inject added academic rigor into NAPs currently transitioning to Doctor of Nursing Practice programs. Likewise, NAPs offer a professional haven for those anesthesiologists seeking new challenges in education, and a unique opportunity to shape the future of anesthesia. Most importantly, introducing anesthesiologists into the initial educational phases of the nurse anesthesia profession provides an opportunity to grow trust and understanding between these two professions that are critical for safe, healthy, and lasting partnerships in future years.

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2

PURPOSE OF REVIEW

With an ageing population, mounting pressure on the healthcare dollar, significant advances in medical technology, and now in the context of coronavirus disease 2019, the traditional paradigm in which operative procedures are undertaken is changing. Increasingly, procedures are performed in more distant, isolated and less familiar locations, challenging anaesthesiologists and requiring well developed situational awareness. This review looks at implications for the practitioner and patient safety, outlining considerations and steps involved in translation of systems and processes well established in the operating room to more unfamiliar environments.

RECENT FINDINGS

Despite limited nonoperating room anaesthesia outcome data, analysis of malpractice claims, anaesthesia-related medical disputes and clinical outcome registries have suggested higher morbidity and mortality. Complications were often associated with suboptimal monitoring, nonadherence to recommended guidelines and sedationist or nonanaesthesiologist caregivers. More recently, clear monitoring guidelines, global patient safety initiatives and widespread implementation of cognitive aids may have contributed to nonoperating room anaesthesia (NORA) outcomes approaching that of traditional operating rooms.

SUMMARY

As NORA caseloads increase, understanding structural and anaesthetic requirements is essential to patient safety. The severe acute respiratory syndrome coronavirus 2 pandemic has provided an opportunity for anaesthesiologists to implement lessons learned from previous analyses, share expertise as patient safety leaders and provide valuable input into protecting patients and caregivers.

Impact of the COVID-19 pandemic on anaesthesia trainees and their training

Coronavirus disease 2019 (COVID-19; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] has dislocated clinical services and postgraduate training. To better understand and to document these impacts, we contacted anaesthesia trainees and trainers across six continents and collated their experiences during the pandemic. All aspects of training programmes have been affected. Trainees report that reduced caseload, sub-specialty experience, and supervised procedures are impairing learning. Cancelled educational activities, postponed examinations, and altered rotations threaten progression through training. Job prospects and international opportunities are downgraded. Work-related anxieties about provision of personal protective equipment, and risks to self and to colleagues are superimposed on concerns for family and friends and domestic disruption. These seismic changes have had consequences for well-being and mental health. In response, anaesthetists have developed innovations in teaching and trainee support. New technologies support trainer–trainee interactions, with a focus on e-learning. National training bodies and medical regulators that specify training and oversee assessment of trainees and their progression have provided flexibility in their requirements. Within anaesthesia departments, support transcends grades and job titles with lessons for the future. Attention to wellness, awareness of mental health issues and multimodal support can attenuate but not eliminate trainee distress.

Students' perceptions of debating as a learning strategy: A qualitative study

Debate has been shown to develop critical thinking skills, enhance communication, and encourage teamwork in a range of different disciplines, including nursing. The objective of this study was to explore students' perceptions of the educational value of debate. A semi-structured focus group was conducted with 13 undergraduate Operating Department Practice students following a debate on the opt-out system of organ donation. Transcripts were analysed thematically, identifying three main themes that described the students' perceptions of the debate. These were: (1) openness to diverse viewpoints; (2) developing non-technical skills, and (3) encouraging deep learning. The analysis showed participants perceived debate to be a valuable educational method that enhanced their learning. Engaging in debate encouraged students to critically reflect on their prior beliefs about organ donation-in some cases leading them to reconsider their original position. The findings from this study suggest that debate can be a valuable pedagogical tool to incorporate into healthcare education. Future research should consider the use of debate to develop non-technical skills that have utility in healthcare.

Who's who? Championing the '#TheatreCapChallenge'

Our Developing Perioperative Practice service improvement project, sponsored by the Royal Bournemouth Hospital, addressed whether the remarkably simple idea of putting names and roles on hats in theatre would improve communication and patient care. We were inspired by our own experiences as a group of student Operating Department Practitioners: unfamiliarity with members of the team, wanting to feel included in the work but not out of our depth, and by social media campaigns such as the '#TheatreCapChallenge' and '#hellomynameis', aiming to humanise care and increase patient safety. Researching, clinically trialling and presenting this project gave us a systematic approach to improving the quality of care within the theatre environment.

Key Factors for Successful General Anesthesia of Obese Adult Patients

PURPOSE

To study nurse anesthetists' experiences of key factors for successful airway management in general anesthesia of adult obese patients.

DESIGN

The study was a qualitative observational study with a descriptive approach.

METHODS

Eight semistructured interviews were conducted. Data were analyzed using the critical incident technique.

FINDINGS

Five key factors for successful general anesthesia of adult obese patients were identified. These factors were preparing and planning the anesthesia, optimizing patient position, optimizing ventilation through proper preoxygenation and increasing positive end-expiratory pressure, quickly securing the airway, and working in teams.

CONCLUSIONS

Knowledge of key factors that facilitate and improve the anesthesia care of obese patients is important to provide safe and quality anesthesia to this patient group as obese patients often have small margins and urgent situations can quickly arise. This knowledge enables the nurse anesthetist to be one step ahead and to be ready to take action if complications occur.

Transforming Health Care One Team at a Time: Ten Observations and the Trail Ahead

The present review synthesizes existing evidence and theory on the science of health care teams and health care team training. Ten observations are presented that capture the current state of the science, with applications to both researchers and practitioners. The observations are drawn from a variety of salient sources, including meta-analytic evidence, reviews of health care team training, primary investigations, and the authors’ collective expertise in developing and implementing medical team training. These observations provide insight into the team (e.g., psychological safety) and organizational-level (e.g., culture for teamwork) factors that drive effective health care teamwork, as well as advancements and best practices for designing and implementing team training initiatives (e.g., multilevel measurement). We highlight areas where new knowledge has emerged, and offer directions for future research that will continue to improve our understanding of health care teams in the future.

Analyzing How Discursive Practices Affect Physicians' Decision-Making Processes: A Phenomenological-Based Qualitative Study in Critical Care Contexts

An intensive care unit (ICU) is a demanding environment, defined by significant complexity, in which physicians must make decisions in situations characterized by high levels of uncertainty. This study used a phenomenological approach to investigate the decision-making (DM) processes among ICU physicians’ team with the aim of understanding what happens when ICU physicians must reach a decision about the infectious status of a patient. The focus was put on the identification of how the discursive practices influence physicians’ DM processes and on how different ICU environments make different discursive profiles emerge, particularly when a key issue is at the center of the physicians’ discussion. A naturalistic approach used in this study is particularly suitable for investigating health care practices because it can best illuminate the essential meaning of the “lived experiences” of the participants. The findings revealed a common framework of elements that provide insight into DM processes in ICUs and how these are affected by discursive practices.

Validity Evidence of Non-Technical Skills Assessment Instruments in Simulated Anaesthesia Crisis Management

We sought to evaluate the validity of two non-technical skills evaluation instruments, the Anaesthetists’ Non-Technical Skills (ANTS) behavioural marker system and the Ottawa Global Rating Scale (GRS), to apply them to anaesthesia training. The content validity, response process, internal structure, relations with other variables and consequences were described for validity evidence. Simulated crisis management sessions were initiated during which two trained raters evaluated the performance of postgraduate first-, second- and third-year (PGY-1, PGY-2 and PGY-3) anaesthesia residents. The study included 70 participants, composed of 24 PGY-1, 24 PGY-2 and 22 PGY-3 residents. Both instruments differentiated the non-technical skills of PGY-1 from PGY-3 residents (P <0.05). Inter-rater agreement was measured using the intraclass correlation coefficient. For the ANTS instrument, the intraclass correlation coefficients for task management, team-working, situation awareness and decision-making were 0.79, 0.34, 0.81 and 0.70, respectively. For the Ottawa GRS, the intraclass correlation coefficients for overall performance, leadership, problem-solving, situation awareness, resource utilisation and communication skills were 0.86, 0.83, 0.84, 0.87, 0.80 and 0.86, respectively. The Cronbach's alpha for internal consistency of the ANTS instrument was 0.93, and was 0.96 for the Ottawa GRS. There was a high correlation between the ANTS and Ottawa GRS. The raters reported the ease of use of the Ottawa GRS compared to the ANTS. We found sufficient evidence of validity in the ANTS instrument and the Ottawa GRS for the evaluation of non-technical skills in a simulated anaesthesia setting, but the Ottawa GRS was more practical and had higher reliability.