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Abstract
Background The time-out procedure is a critically important communication interaction for the preservation of patient safety in the surgical setting. While previous research has examined influences shaping the time-out procedure, limited information exists on how actual time-out communication is performed by multidisciplinary surgical team members in the clinical environment.
Methods An institutional ethnographic study was undertaken. The study was conducted over three hospital sites in Melbourne, Australia. In total, 125 healthcare professionals from the disciplines of surgery, anaesthesia and nursing participated in the study. Data were generated through 350 h of observation, two focus groups and 20 semi-structured interviews. An institutional ethnographic analysis was undertaken.
Results Analysis revealed healthcare professionals adapted the content, timing and number of team members involved in the time-out procedure to meet the demands of the theatre environment. Habitually, the time-out procedure was partially completed, conducted after surgery had commenced and involved only a few members of the surgical team. Communication was restricted and stifled by asynchronous workflows, time restrictions, a hierarchical culture and disinclination by surgeons and anaesthetists to volunteer information and openly communicate with each other and nurses. Healthcare professionals became normalised to performing an abbreviated time-out procedure.
Conclusions Patient safety was relegated in importance as productivity, professional and hierarchical discourses configured the communication practices of surgical team members to limit active, open and direct communication. Examining how the time-out procedure was conducted in the clinical environment enables possibilities to emerge for facilitating compliance with hospital and WHO guidelines.
- Communication
- Surgery
- Qualitative research
- Safety culture
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Introduction
The literature on surgical procedures going awry is concerning, particularly as many surgical complications are avoidable.1 In Australia and internationally, many sentinel and adverse events are reported in relation to surgical procedures.2–4 These events can arise as numerous diverse causes accrue and interact in work settings. The Systems Engineering Initiative to Patient Safety model addresses the role of interrelated components of work systems that shape the services provided by healthcare professionals.5 Components of the model include the person, organisation, tasks, environment, tools and technologies.5 For operating room staff, communication is a key element of work systems, which is intrinsic to performing their activities. Hence, suboptimal communication can unbalance the interlinked work systems and affect the way safe care is provided.5
A key communication interaction undertaken in the operating room is the time-out procedure. The procedure involves a brief pause before a surgical incision is made to check the patient's identity, the operative site and side, and the surgery to be performed.6 As well as verbal communication, the anaesthetist, surgeon and nurse are expected to confirm the operation side, site or sites by inspection.6 Time out is an opportunity for surgical team members to communicate and address any concerns relating to patient safety or the procedure.6 ,7 All healthcare team members delivering surgical care are expected to participate in a time-out communication interaction.6 ,8 Congregation of surgical team members is designed to promote group communication, achieve shared understandings and improve patient safety.7 ,8 However, despite use of the time-out interaction in theatre, surgical procedures on the wrong surgical site and wrong patient and incorrect procedures still occur.2 ,4
Recently, time-out procedures have been incorporated into preoperative checklists, such as the WHO surgical safety checklist. This checklist expands the time-out procedure to incorporate 19 items for checking, divided into three phases: before the induction of anaesthesia, before skin incision and before the patient leaves the operating room.9 Checklists can simplify, standardise and organise tasks, ensuring their completion.10 Additionally, checklists can structure interactions to foster active and transparent verbal engagement, raising the likelihood of successful communication. In turn, the incidence of errors and adverse events may be reduced and patient safety be promoted.10 ,11
Adherence to and implementation of surgical checklists, however, have been problematic in practice.12 ,13 Organisational and sociocultural factors are diverse among surgical specialities and environments, and when these contextual aspects are not accounted for prior to checklist implementation, resistance to checklist use can arise.12 ,14 ,15 Further, while an implementation manual for the WHO surgical safety checklist was published,16 a standardised operating protocol was not included, varying its implementation across settings and potentially diminishing its safety features.12 ,17
Research to date has provided limited insights into how time-out communication interactions are conducted in clinical practice. An Australian group of researchers investigated the time-out procedure by conducting interviews with 16 healthcare professionals and focused on influences shaping the time-out communication interaction.18 However, observation of time-out communication was not undertaken to see how the actual procedure was carried out. While many researchers have concentrated on exploring the use of surgical safety checklists in practice,19–22 limited attention has been paid to the time-out component, restricting the scope of understanding how time-out procedures are accomplished. Hence, the aim of this paper is to explore how the time-out procedure is implemented in clinical practice.
Methods
Research setting and study informants
An institutional ethnographic research design was used. Observations were made in three public, teaching hospitals in Melbourne, Australia, from January to October 2010. These hospitals collectively perform over 20 000 surgical procedures per year. Characteristics of the study hospitals are shown in table 1. Ethics approval was granted by the research and ethics committee of the respective hospitals. One hundred and twenty-five healthcare professionals were purposely selected to act as informants across the perioperative pathway and provided written consent to participate. Their characteristics are shown in table 1. As the selected informants engaged with many others in communication, verbal consent was gained from other individuals participating in communication interactions.
Characteristics of study hospitals and healthcare professional informants
Data collection
Data were collected through more than 350 h of participant observation, two focus groups, and 20 semistructured interviews with informants from each hospital. Information was collected on individuals involved in time-out procedures; when overlapping conversations and multitasking occurred; the types of communication channels used and the causes, outcomes and consequences of communication failure. A single observer, a registered nurse with 20 years’ hospital experience, performed the observations, interviews and focus groups. Data collection commenced in January 2010 and concluded in October 2010. The research settings were initially observed for 1–3 days prior to recording any observations. Informants (N=107) were shadowed for a period of 2–4 h during mornings, afternoons, weekdays and weekends. Observations were made at a distance to enable the informant's speech to be heard clearly, but not so close to be intrusive, cause disruption or contaminate sterile areas. Focus groups and semi-structured individual interviews were conducted over 30–40 min and consisted of a total of 30 informants, 12 of whom had also consented to participate in being observed. Accordingly, a total of 125 healthcare professionals participated in the study.
The time-out policy of the health service listed all items on the time-out component of the WHO checklist, except for confirming the introduction of all team members. Observation for the time-out procedure commenced as soon as the patient entered the theatre. The time-out procedure was considered incomplete once the surgeon made a skin incision or inserted a scope into the patient. Time out was noted as not conducted if it was not completed before the patient was moved out of theatre. To detect if the checklist was wholly or partially completed during the time-out interaction, the researcher marked off components of the checklist in field notes as the items were audibly spoken and checked by theatre staff. Time out was deemed incomplete if an anaesthetist, surgeon and nurse did not confirm the patient, site and procedure or any other relevant components of the checklist. Communication failure was detected according to Lingard et al's23 communication failure definition, where a flaw exists in the audience, occasion, purpose or content of a communication event. How communication failure was detected and categorised is described in table 2.
How communication failure was attributed during observations
Data analysis
Institutional ethnography does not prescribe traditional qualitative data analysis methods of using interpretative coding to organise data into set groups and concepts.24 ,25 Repeated coding of data can distort and obscure the permeating social relations that are at the core of an institutional ethnography.26 However, initial coding of data into indexed ‘chunks’ can assist to broadly organise the data for further analysis.27 Ethnographic field notes, texts and audio transcripts were used to analyse data, uncover the social relations, and trace the institutional ruling relations coordinating healthcare professionals’ communication. Multiple analytical questions proposed by Campbell and Gregor25 and McCoy28 were used to deeply probe the data. The questions posed to lead this analysis are shown in online supplementary appendix 1.
To ensure rigour, the methods of prolonged engagement, triangulation, member checking, peer review and inter-rater reliability were employed. A description of these methods is provided in online supplementary appendix 1.
Results
While 107 surgical procedures were observed, only 102 time-out interactions were witnessed, as time-out communication did not occur on five occasions. Of the time-out interactions, 10% (11/102) were conducted in accordance with the hospital policy. Fifty percent of the time-out interactions involved only a surgeon and a nurse. The most frequently non-completed component of the time-out checklist was involvement of, and contribution by, an anaesthetist (76%, 91/102). The most common reasons for non-participation in the time-out interaction was healthcare professionals were unaware time out was being conducted (94%, 96/102) and they were preoccupied with the completion of other tasks (91%, 93/102). Communication failure occurred in 94% (96/102) of time-out interactions. The characteristics of the surgical procedures and time-out interactions observed are shown in table 3.
Number of surgical procedures observed and characteristics of time-out interactions
In the clinical area time-out communication was routinely performed; however, the procedure was often incomplete. While most surgeons and nurses worked to ensure the time-out procedure took place, it was rarely carried out in accordance with the WHO or hospital policy. Alternatively, an abridged time-out procedure was often performed. The time-out communication encounter typically involved only a nurse and a surgeon, verbally confirmed the patient and procedure only, or was conducted after a patient incision had been made.
Ruling government policy endorsing efficiency and productivity discourses pervasively coordinated constrained communication practices exhibited by healthcare professionals at time-out interactions. In an intertextual hierarchy,29 the government's elective surgery access policy organised how the operating room list was assembled.30 Accompanying government healthcare documents also outlined key organisational performance indicators to be accomplished, such as the set numbers of surgeries to be completed annually.31 Formal monitoring of the health service's performance occurred through regular audits on the numbers and types of surgeries completed.
Limited involvement of surgical team members
Before a surgical procedure, surgeons, anaesthetists and nurses were all actively engaged in performing their role-related tasks. Surgeons were usually busy washing their hands and putting on sterile gowns; anaesthetists were involved in securing a patient's airway and delivering medications. Nurses were typically setting up equipment, opening supplies and performing instrument counts. Thus, surgeons, anaesthetists and nurses worked asynchronously as each discipline went about performing its specific duties before a surgery commenced. These asynchronous workflows impacted on a healthcare professional's ability to halt their work and collaboratively meet to communicate at a time-out procedure:
Time out was about to commence and the nurse initiating it asked the anaesthetist “Are you joining us?” The anaesthetist replies, “No, we have things to do.” [Obs_circnurs_125]
Interdisciplinary group communication rarely occurred. On most occasions, a combination of either a nurse and a surgeon or two theatre nurses, performed the time out. Other surgical team members present in the theatre were busily engaged in discipline-specific preparations for the impending surgery. Thus, as two theatre staff members with no participation from the broader surgical team routinely conducted time out, communication failure occurred.
Often anaesthetists did not participate in time-out communication, as usually no invitation was extended by other staff to involve the anaesthetist, and no announcement was made that the time-out procedure was being conducted. Indeed, anaesthetists justified their non-participation in time-out communication in terms of time restrictions, competing interests and lack of relevance. An anaesthetist (213) rationalised his absence from time-out communication by stating, “It [time out] takes a long time if everyone is involved.... Everyone's busy doing their own jobs. We just need to get on with treating patients; there are enough people on the waiting lists for surgery as it is”. Another anaesthetist (211) expressed his disconnection from the time-out procedure owing to no perceived need to be involved: “I will call or contact the surgeon prior to the procedure if I have any concerns”.
Healthcare professionals’ asynchronous work routines, combined with organisational pressures to complete operating room lists in limited timeframes, restricted opportunities for information to be collaboratively shared. Healthcare professionals seemed normalised to these ubiquitous occurrences, and to the notion that group interdisciplinary communication at the time-out procedure was unnecessary. Interestingly, even when opportunities for collaborative communication before surgery occurred, healthcare professionals still did not actively converse in a time-out interaction. If an unexpected delay provided time before surgery, theatre staff would usually disperse into groups to communicate with individuals from their own discipline on topics unrelated to the patient and impending procedure. The consequence of communication failure owing to non-active and limited engagement of surgical team members, was that not all healthcare professionals possessed the same patient and procedural information before the commencement of surgery.
Time out after incision
Striving to meet demands of the operating room list, healthcare professionals worked under time-pressured conditions. To maximise operating room time and space and avoid delaying surgeons, healthcare professionals worked hastily. This ensured the theatre area was set up and that the patient was anaesthetised in a timely manner. However, in the rush to commence operating, the time-out procedure was sometimes overlooked:
The surgeon had cut the patient's skin and a nurse asks, “Did we do a time out?” The anaesthetist says “No, but we should keep it legal”. The time out is performed, but as the surgeon had started operating he was not involved. [Obs_nursecoord_121]
Sometimes things are rushed before surgery, but theatre time out is always conducted, even if I can't be involved. [Surgeon_308]
While on most occasions healthcare professionals incorporated the time-out procedure into their work prior to the first incision, the goal of promptly commencing a patient's surgery sometimes took precedence. On other rare occasions, the time-out procedure was omitted entirely; this usually occurred when emergency surgery was required and surgical intervention was time critical. Thus, owing to flaws in the purpose and timing of the time-out interaction, communication failure transpired.
Surgical teams worked under constant time pressures, and overt and covert evidence of time constraints was ever present. Overbooked operating room lists, audits on theatre starting times, surgeon demands for patient flow through theatres and regular incorporation of unplanned emergency cases into theatre, all served to remind healthcare professionals of time limitations. Thus, owing to the pervasive influence of time, healthcare professionals routinely ordered and negotiated their work based on this priority. While the time-out procedure was recognised as a necessary requirement by surgical team members, it did not always take precedence over adherence to time restrictions. Hence, the time-out procedure was relegated as other tasks of greater perceived importance were addressed. Accordingly, time-out communication occurred after an operation was commenced or occasionally the time-out procedure was entirely omitted.
Failure to perform the time-out procedure before a patient's skin was cut also took place when surgeons did not inform other theatre team members of their intention to make an incision. Sometimes, a surgeon would commence an operation before nursing staff had completed their preparations. Nurses, busy fulfilling last minute requests made by surgeons, were distracted from seeing a surgeon beginning operating. As nurses customarily instigated the time-out procedure, any distraction or interruptions to nurses’ routines had the potential to lead to delays or omissions in the time-out procedure. A theatre nurse (125) commented “We [nursing staff] always initiate the time out. I don't think it would ever be done otherwise”. The consequences of time-out communication occurring after an incision had been made were tension among surgical team members (when the surgeon gave no warning before starting a surgery) and diminished safety for the patient.
Partial completion of the time-out procedure
Time-out communication was of short duration, rarely lasting more than 1 min. While the process of completing time out was generally ingrained into the work processes of nursing staff and some surgeons, these healthcare professionals routinely abbreviated the procedure. A theatre nurse summarised what was observed to be commonplace in theatres:
There is no group communication! We just check the patient's name, UR [unique record number] and procedure, and we are straight into it [the surgery]. [Focus_group_theatrenurs_123]
The patient was admitted for removal of screws from his right ankle. At time out the surgeon and nurse read out the patient [name], procedure and site of surgery, but the site of surgery was never physically checked. The patient's legs remained under the blankets. [Obs_surg_303]
To integrate the mandated hospital policy on time out into the practicalities of their time-restricted work, theatre staff unofficially implemented an abridged time-out procedure. The procedure was simplified and shortened by reducing the number of staff involved and limiting the details to be authenticated by not physically checking the site of surgery. Adapting the hospital's time-out procedure enabled theatre staff to work quickly and facilitated integration of the procedure into the daily work routines of surgical teams. However, this abbreviated time-out interaction incorporated only selected aspects of the hospital's procedural requirements and was not endorsed by the healthcare organisation. Communication failure ensued owing to limited content in, and failure to attain the purpose of, time-out communication.
Further contributing to partial completion of the time-out procedure were nurses’ disinclination to question surgeons regarding the impending surgery and surgeons’ and anaesthetists’ reluctance to disclose their needs. Nurses were hesitant to utilise the time-out procedure to explore or confirm the likely requirements of a surgeon or an anaesthetist during surgery. Nurses either felt intimidated to ask for information, or their experiences of asking proved to be of little benefit. As shown and described by two theatre nurses:
It's [time out] just to check right patient, right procedure. If I need to know something I'll ask one of the other nurses. We [nurses] are very subservient to the surgeons; we pretty much do as we are told. I don't like to question. [Theatre_nurs_131]
Prior to the commencement of surgery the theatre nurse asked the surgical consultant to review the equipment for surgery. The surgeon declined, stating, “We kind of make it up as we go”. [Obs_theatre_nurs_123]
Given the routine of little or no interdisciplinary communication taking place during the time-out procedure, nurses often did not attempt to alter its established format. Rather, nurses accepted partial completion of the time-out procedure as custom. To gather information, nurses preferred to consult sources of information other than surgeons, such as other nurses or surgeon preference cards. Without the benefit of clear forewarning by surgeons and anaesthetists of their likely needs during the surgery, nurses worked reactively. Although the lack of timely notification of surgical needs caused nurses to work inefficiently, nurses choose to rarely verbally protest or directly challenge a surgeon's authority. Workflow inefficiency was evident as nurses recurrently chased up instruments, equipment and radiological services, causing surgical delays. An additional consequence of communication failure from partial completion of the time-out procedure was diminished safety for the patient.
Online supplementary appendix 2 provides additional quotes from the research informants for each of three result categories.
Discussion
Exploring how the time-out procedure is implemented in clinical practice is of significant interest, for this critical communication interaction is intrinsic to the delivery of safe patient care. This paper presents important knowledge through examining how the time-out procedure was carried out in busy theatre environments, in contrast to how the procedure should be conducted according to WHO and hospital guidelines.
Working within the constant constraint of time restrictions, time-out interactions were predominantly partially completed. Anaesthetists were often uninvolved and only limited components of the checklist were confirmed. Reducing the number of items checked and the extent of healthcare professionals’ involvement shaped the communication interaction to fit into busy, time-restricted pre-surgery work routines. This unofficial adaptation of the time-out procedure can be traced back to healthcare professionals working diligently to maintain a steady flow of patients in and out of theatre. Coordinated by ruling discourses of productivity and efficiency, healthcare professionals aligned their work with the operating room list, which was an organising document designed to ensure that theatre time and space were maximally utilised.
Our findings identified that the time-out interaction was not conducted as an open collaborative communication opportunity and vital safety check. Nurses were reluctant to address their information needs at the time-out procedure and on occasions surgeons commenced operating before the time-out procedure was conducted. Further, anaesthetists sometimes declined to participate in time out, and when time was allowed for all healthcare professionals to collaboratively communicate before surgery, they did not always actively converse.
Discourses of professional practice and hierarchical dominance converged to inhibit collaborative communication at the time-out procedure. As doctors enjoyed higher positioning in the hierarchy than nurses, the unequal power relations caused nurses to feel uncomfortable with approaching anaesthetists and surgeons for information. In line with Gillespie et al's32 view, healthcare professionals demonstrated strong tribal affiliations to their own professional discipline, which contributed to surgical, nursing and anaesthetic teams acting as independent units.
Additionally, surgeons’ and anaesthetists’ work and communication processes reflected discourses of independent practice. Displaying strong professional identities and possessing detailed patient and procedural knowledge, surgeons and anaesthetists routinely carried out their work independently. However, professional independence led to information ownership and the inclination to work individualistically. As noted by Nagpal et al,33 individuals holding information led to no theatre staff member possessing all the patient and procedural knowledge relevant to the case at hand. Accordingly, in our study, critical information was indirectly distributed and gained in an informal, untimely and haphazard manner. These results support the findings of Lingard et al,10 ,34 which also revealed communication failure prior to surgery stemming from a disorganised approach to information distribution.
Theatre staff displayed a clear sense of duty to perform time-out communication, but they abridged the procedure to fit in with their busy work conditions. The adapted time-out communication became a cultural habit, as the procedure was performed consistently as a mundane automated task. Healthcare professionals might have subsequently lost sight of the purpose of the procedure and understanding of how to perform it as outlined by hospital and WHO guidelines. Nonetheless, time out was routinely performed by a combination of a nurse and a surgeon, or two nurses together. Nurses’ consistent involvement in time-out interactions may relate to them equating adherence to hospital procedures with discourses of professionalism.35 The lack of regular participation by medical staff may reflect their rejection of highly prescriptive policies and desire for professional autonomy.35
Discourses of quality and safety were also evident in healthcare professionals’ work and communication. However, practices associated with quality and safety activities were time consuming. Healthcare professionals, accordingly, found themselves embedded in a complex web of ruling relations coordinating their work in the clinical environment. Healthcare professionals reconciled this dilemma by streamlining the time-out procedure to partially meet safety and quality standards, as well as adhere to ever-present efficiency and productivity demands. The consequences of communication failure during the time-out procedure were ultimately inefficiency, rushing and increased workload, as well as the exchange of minimal patient and procedural information among theatre staff. Minimal information exchange prevented the attainment of mutual understandings, which potentially compromised healthcare professionals’ decision making and therefore patient safety.
The results of our study were often in clear contrast to the WHO time-out guidelines. Adherence to the WHO time-out guidelines, however, is only part of the solution for surgical teams to reduce avoidable risks. For surgical teams to successfully communicate, the culture of minimal interdisciplinary communication at time-out interactions must change. To enable patient and procedural information to flow freely at time-out interactions, healthcare professionals require sufficient time to synchronise their workflow. To foster active and effective communication, steep hierarchies must be flattened and tolerance displayed for open questioning by co-workers. Such transformations are unlikely to occur without communication and team training and strong leadership to initiate and sustain change. Furthermore, patient participation in confirming their identity, site of surgery and procedure could add a further layer of safety protection to the time-out communication process.9
Future research needs to explore the impact of interdisciplinary communication education programs on surgical teams’ implementation of, and adherence to, time-out procedure guidelines. Further, government departments writing healthcare policies that determine hospital performance indicators must take into account the communication challenges faced by surgical teams for delivering safe patient care in constrained timeframes.
Limitations of the study
It is possible that staff who consented to act as informants were particularly interested in communications research or were confident in their communication skills. Nevertheless, as many communication gaps were identified, it is unlikely that these aspects affected data collection. Further, the presence of the first author in the perioperative environment might have caused an undue focus on improving communication. However, as over 350 hours of observations were conducted, after a short period of time the repeated and extended presence of the first author drew very little attention and comment.
Conclusion
This study has highlighted complex issues surrounding how the time-out procedure is implemented in clinical practice. Patient safety was relegated in importance as ruling discourses configured the communication practices of surgical team members to limit active, open and direct communication at time-out interactions. To align and sustain healthcare professional communication processes with patient safety, awareness of actual communication behaviours at the time-out procedure is vital to communication improvement and compliance with guidelines.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Files in this Data Supplement:
- Data supplement 1 - Online appendix 1
- Data supplement 2 - Online appendix 2
Footnotes
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Contributors All authors listed are entitled to authorship through their substantial contribution to completion of the manuscript. Individual contributions of the authors are as follows: Conception and design of the study: EMs, RR and SB. Acquisition of the data: SB, EM and RR. Analysis and interpretation of the data: SB, EM and RR. Drafting the article: SB and EM. Revising the article for critically important intellectual content: EM. Final approval of the article: SB, EM and RR.
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Funding This research was supported by the Australian Research Council Linkage Project Grant (number: LP0883265) and Eastern Health provided financial support for this research. These funding bodies were not involved in the conduct of the research.
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Competing interests None.
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Ethics approval Eastern Health Research and Ethics Committee.
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Provenance and peer review Not commissioned; externally peer reviewed.
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Data sharing statement As further publications are planned from the data, data sharing is not possible at this stage.