Communication as a non‐technical skill in the operating room: A qualitative study

Abstract Aim The aim of this study was to explore how operating room nurses (ORNs) experience operating room (OR) team communication concerning non‐technical skills. Design Based on the Scrub Practitioners List of Intraoperative Non‐Technical Skill (SPLINTS), qualitative individual in‐depth semi‐structured interviews were conducted with 11 ORNs in a Norwegian university hospital. Braun and Clarke's six analytic phases for thematic data analysis were used. Results Surgeons being unprepared or demanding different instruments than the preoperative information indicates, cause stress and frustration. So does noise and brusquely or poor communication. Ensuring good information flow within the entire team is important. When silence is required, the ORNs communicate with gestures, looks and nods. Creating a positive and secure team culture facilitates discussions, questions and information sharing. Conclusion Inappropriate dynamics, inaccurate and/or disrespectful communication and noise may reduce patient safety. Interdisciplinary team training may bring attention to the value of communication as a non‐technical skill.


| DE S I G N AND ME THOD
This study has a qualitative design where individual in-depth interviews were conducted to learn how ORNs in a central perioperative unit in a Norwegian university hospital experienced the use of communication concerning non-technical skills in the OR team in light of the SPLINTS assessment tool (Flin et al., 2014). The central perioperative unit in question has about 90 perioperative nurses, 14 operating rooms and seven sub-units or specialties: gynaecology, vascular/thorax, gastroenterology, urology, ear/nose/throat, endocrinology and orthopaedics.
A qualitative semi-structured interview guide was used based on SPLINTS' three main areas. In this paper, SPLINTS' main area 2, communication and teamwork, is focused. This pertains to acting assertively, exchanging information and coordinating with others.

| Data collection
Before the interviews took place, all the unit's ORNs were informed about the study. Of the 47 nurses who fulfilled the inclusion criteria, 11 accepted the invitation to participate in the study. Their names were given to the first and second authors through their respective sub-unit heads. The interviews were conducted in a quiet room in the hospital's perioperative unit with only the interviewer and the interviewee present. All the interviews were performed during the respective interviewee's day shifts.
Inclusion criteria: ORNs with more than five years experience as supervisors for perioperative nursing students. There were no specific exclusion criteria.
As seen in Table 1, the mean age of our interviewees was 52 years.
What the concept "non-technical skills" entails was discussed with the interviewees before the interviews were commenced. The interviews, lasting 21-79 min, took form of an electronically recorded talk where the interviewees were encouraged to recount their experiences.

| Interview guide
Regarding communication and teamwork, the interviewees were asked the following questions: • How do you cooperate and exchange information within the team/with co-workers?

| ETHICAL CONSIDERATIONS
The project was approved by the Norwegian Centre for Research Data in care of the hospital's Data Protection Officer. The interviewees were informed in writing and orally that participation was voluntary and that they were free to withdraw from the project whenever they wanted without giving any explanation. They all gave their written informed consent to participate. Interview transcriptions are stored safely according to Ethical Research Guidelines (Helsedirektoratet, 2009).
Recorded interviews were deleted after transcription.

| Data analysis
The first author conducted the interviews. She and the second author transcribed the interviews verbatim. These two authors are both ORNs, while the third author is not and therefore had an outsider view on the data. Thus, we tried to minimize bias and strengthen trustworthiness. All three authors took part in the data analysis which was thematic and hermeneutic in character where depth of understanding was attained through a circular investigation of the interviews (Gadamer, 2012). Braun and Clarke's (2006) six analytic phases for thematic analysis were used: 1) The authors familiarized themselves with the data. 2) Interesting features were coded and collated into potential themes (phase 3, searching for themes). Phases 4 (reviewing themes) and 5 (defining and naming themes) (Braun & Clarke, 2006) were done collaboratively by all the authors. 6) The first author wrote a preliminary paper text which then was discussed and developed further collaboratively. All the while, we tried to be open, curious, communicate authentically, and to realize that the fusion of horizons through the reading of texts leads to the creation of something new (Gadamer, 2012) and to avoid bias. Both the first and second authors have previous qualitative researcher experience. Even so, a professor of nursing, well versed in qualitative research, was invited in as co-analyst, co-author and mentor. This was done to avoid analytic bias and to add depth of reflection to the analyses.

| Trustworthiness
Trustworthiness and rigour were obtained through following Braun and Clarke's (2006) phases of thematic analysis while we read and re-read the interview texts and thus strived to "remain open to the meaning of the other person or the text" (Gadamer, 1989, p. 268).
The study's credibility is ensured through the choice of context, participants and research approach suitable for the focus of our study. Quotations/telling meaning units are presented to emphasize our findings (Polit & Beck, 2014). This also strengthens the study's confirmability as it shows that the findings are based on our interviewees' responses and not on potential bias or any personal motivations that would skew our interpretations (ibid). Dependability is achieved through interviewing ORNs with varied and extensive experience, presenting the basic questions asked during the interviews, and following the chosen model for data analysis step by step.
Thus, it will be possible to repeat the study in a similar OR setting by other researchers and acquire findings in line with ours. And finally, trustworthiness through transferability is achieved by presenting thick descriptions to show that the study findings can be applicable to other OR similar contexts, circumstances and situations.

| RE SULTS
Central in the interviews are factors that may influence communication and the exchange of information within the OR team.

| Factors that may influence communication
According to several of the interviewees, some surgeons take it upon themselves to define who may speak in the OR and who may not. Others restrict their communication to barking commands.

Sometimes surgeons communicate important information too late
for the ORN to have the correct instruments-or rather-the surgeons' preferred instruments available. Or they may have a brusque way of imparting information and orders, something which may create uncertainty within the team. Nurse #7 even finds that she has to "be prepared to 'accept' unpleasant communication to maintain a good atmosphere in the OR." This kind of unidirectional and hierarchical communication influences the OR team in a negative way. Experienced ORNs have learned to handle these surgeons, but found them rather daunting when they were new to this field of nursing. As Nurse #1 put it: "Experienced operating room nurses find it easier to be heard than those who are new. With experience it is easier to speak your mind." This latter point is important as the ORNs regard themselves as the patients' advocate. It is essential for them to argue for the patients' Several surgeons working together may enhance this challenge as it impairs the situational overview the ORNs need to be effective and efficient assistants. At times some surgeons have an internal conversation going and then they suddenly may give orders without changing the volume or pitch of voice, making the order difficult to catch. The interviewees saw "mumblers" and foreign co-workers who master the Norwegian language poorly as particularly problematic: "And of course, if there are some with a foreign language that makes it hard to communicate, this may create difficulties." (#11).
Noise also impairs team communication. Several interviewees mention this in connection with the completion of large and complicated surgical procedures, particularly when "we are to count equipment and instruments." Then the noise level tends to be very high with "a lot of unnecessary unrelated talk. And we are two operating room nurses who are to count these things but are not given the quiet and the time to do the job. And it is a job we have to finish before the patient is taken to the post-operative unit" (#4).

| Exchange of information within the OR team
Securing correct preoperative information about the patient and the surgical procedure is pointed out as essential for being prepared for the work that is to be done in the OR. Insufficient preparation may influence the result negatively. The notes written by the surgeon the previous day are therefore considered as very important. When "the scheduled surgery has a different surgeon than planned and the procedure turns out to be different from the information we are given" (#3), this interferes with the ORNs' work as both the positioning and the surgical draping of the patient might have to be changed after the arrival of the surgeon. When in doubt, the ORNs often call the surgeon beforehand to make sure that everything is according to his or her preferences.
The patient is him-/herself an important source of information.
Except for those who are being operated in regional and local anaesthesia, most patients are awake only for a limited time in the OR ahead of surgery. In this often brief period, the interviewees try to learn as much as possible from the patients that may be important for the procedure: "I ask the patients if they for instance have a total hip or knee replacement and other issues regarding the body related to how they have to be positioned on the table. I use the time while moving the patient from the preoperative room into the OR to talk about such matters. This way a conversation is started, and the patient often spontaneously tells me things that help me understand what is important to this person in this particular situation" (#4).

To mediate information between the members of the OR team
perioperatively is perceived as equally important. This includes "all the various interdisciplinary discussions. It is very important to share this with the entire team so that everyone is informed and understands that we were going in that direction, but now we have turned forty-five degrees to the right because we now have decided to do something different because of this and that. So that everyone is up to speed" (#4).

During particularly complicated or precarious operations, the
ORNs do their best not to disturb the surgeons by asking questions. When oral communication is difficult, for instance because of noise, or talk for some reason should be avoided "I look at my colleague who is assisting me: Did you understand that we need different equipment? And she merely nods. When we are two who have worked together for years, it is a very good feeling. Most things are done by looks and small gestures … discrete hand movements without the use of much energy. We look at each other and agree on things. I find that to be a good way of communicating" (#4).
A friendly atmosphere opens up for the asking of questions. In such an atmosphere the interviewees find it easier to share information and even point out errors made by team members. It furthermore makes the ORNs feel appreciated and creates a positive team feeling.

| D ISCUSS I ON
The supported by frequent, timely, accurate, and problem-solving rather than blaming communication." They claim that this leads to "higher levels of quality, efficiency, and job satisfaction as well as work engagement, psychological safety and the ability to learn from errors." The importance of respectful, adequate and informative communication is supported by Penprase, Elstun Ferguson, Schaper and Tiller (2010) who connect it to patient safety, reduction of uncertainty within the perioperative team and the promotion of harmonious teamwork which enhances efficient care and job satisfaction. This is in line with our findings.
While good communication reduces stress, uncertainty inhibits communication and causes stress. Leonard, Graham and Boacum (2004) hold that "[h]ierarchy, or power distance, frequently inhibits people from speaking up." Their study shows that condescending and disrespectful communication may be the result of a power distance that tends to create lack of psychological safety, unhealthy cultural norms and uncertainty as to the plan of action. Furthermore, tension among team members that negatively influence communication and collaboration is among the factors that may lead to procedural errors (Garrett, 2016;Jenkins, 2015;Lingard et al., 2004;Penprase et al., 2010;Pires et al., 2017) and patient harm (Høyland et al., 2011;Youngson & Flin, 2010).
Our interviewees emphasized the importance of the surgical team members understanding each other's responsibilities. They also found it useful to know how individual surgeons wanted the OR prepared for various specialized surgeries as this created a positive Thus, all perioperative team members are enabled to effectively manage their roles and responsibilities (Garrett, 2016). The sharing of knowledge within the team is required, something which is chal- Surgeons tend to report higher satisfaction with the teamwork climate and communication than nurses, and they experience communication and teamwork different from the rest of the OR team (Mills et al., 2008;Sexton et al., 2000). They also tend to describe a stronger safety culture than other team members. The reason behind this may be a gap in communication styles between nurses and physicians (Sexton et al., 2000).
Differences in communication styles are not the only problem, however. Many of our interviewees held that noise impaired team communication during surgery. Several also mentioned noise in connection with the counting of instruments at the completion of surgical procedures. This is perceived as a stressor and something that potentially may influence patient safety negatively. In the interest of patient safety, it is important for the ORNs to be able to concentrate on their work despite the immense demands on their attention (Ingvarsdottir & Halldorsdottir, 2018 According to Tørring et al., (2019), this type of silent interpersonal dynamic appeared when the team members performed safe-surgery procedures. As in our study, the verbal exchange of information during these procedures was often very brief.
Our interviewees worried that insufficient preparation could influence negatively on the outcome of the surgical procedure. They found that unexpected changes of surgeons or procedures created stress and last-minute reorganization and replacement of instruments to suit the new setting. If they became aware of these changes in time, they would call the surgeon to receive the information they needed. Otherwise, they had to do the changes after the surgeon was ready to start. These were problems also seen by  (Flin et al., ,,,,,,,,2008(Flin et al., ,,,,,,,, , 2014. Such an analytic approach to "real-life" contexts together with interdisciplinary team training may bring attention to the value of communication as a nontechnical skill and how this affects team performance, patient safety and treatment outcomes (Ballangrud et al., 2014).