A critical ethnography approach is useful in understanding phenomena such as silence and constraint in communication, which are ambiguous and difficult to record and interpret ‘objectively’. Butler (1997) critiques what she refers to as Bourdieu’s static notion of authority, however. Also, it is not only that the nurses speak quietly, but also that there is often a contrast in their volume compared to that of surgeons, who will often speak loudly. » Intentional silence can enhance the therapeutic relationship between the nurse and patient. Anesthesiologist: ‘He’s gotten some antibiotics’. They may have been inclined not to bother the surgeons, but they may also have perceived this to be within their scope of practice and thus did not want to ask in order to save face. Culture, Silence and Voice: The Implications for Patient Safety in the Operating Theatre. In this sense, the action of the surgeon may be seen as a form of silence deployed to resist the institutional practice of the pause. Speech is a means of self‐expression, but may also be used to silence others or may reflect a lack of individual agency if it takes the form of participation in regulatory or normative discursive projects. A nurse says quietly, to herself, ‘No speak English’, but does not inform the surgeon that the patient does not understand what he is saying. Knowledge and agency in interprofessional care: How nurses contribute to the case-construction in an Intensive Care Unit. She gives the example of the tell‐all, confessional discourse pervading modern western culture; not participating in this discourse by adopting a stance of silence may afford a measure of freedom. Policies such as the ‘surgical pause’ tend to focus on speech and speaking. 10, no. Just a Routine Operation: A Critical Discussion. A second surgical resident says, ‘There always is’. Understanding and Optimizing Tourniquet Use During Extremity Surgery. Silence in Interdisciplinary Research Collaboration: Not Everything Said is Relevant, Not Everything Relevant is Said. This site needs JavaScript to work properly. This article presents the author's personal reflection on how her nursing practice was enhanced as a result of losing her voice. 1997 Mar 13-26;6(5):275-9. doi: 10.12968/bjon.1997.6.5.275. Following Foley (2002, p. 473), we seek ‘provisionally accurate’ interpretations, for we ‘understand that writing is inscription, an evocative act of creation and of representation’ (Denzin 1997, p. 25–26). Instead he’s placed them on a rubber mat on the patient’s chest. Re‐use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit commercial exploitation. In fact, power struggles between nurses and surgeons are often most explicit in interactions over nurses’ power and positioning as sanctioned supervisors of institutional ‘rules’. In the following example, there appears to be a level of tension felt by the scrub nurse in speaking, such that she repeatedly performs a complicated physical manoeuvre, rather than giving a brief oral instruction to the surgical team, which the surgeon repeatedly invites her to provide: This communication event takes place over a 45 minute period. To the extent that silence is revealing of dynamics of power and privilege, it is important to ‘listen’ to silence (Mazzei 2007). In our data set, anaesthesiologists tended to talk and interact less overall, so that we had fewer opportunities to capture their communication or to characterize their silences by references to contextualizing speech. These silences may be defensive or strategic, and they may be influenced by larger institutional and structural power dynamics as well as by the immediate situational context. Silence is often uncomfortable for the home healthcare nurse and the client, but when silence is used purposefully by the nurse, effective communication can be a successful intervention. Number of times cited according to CrossRef: Approaches for Inserting Neurodynamics into the Training of Healthcare Teams. Preventable Surgical Harm in Gynecologic Oncology: Optimizing Quality and Patient Safety. Conclusions. For Bourdieu, the efficacy of a speech act is contingent on the authority of the speaker, and that authority derives from institutional power. What’s Behind the Scenes? Recurring instances of non‐response and inefficacious speech acts convey strongly the difficulties nurses encounter in communication in the OR, but also areas of daily conflict and negotiation over how communication will take place in the interprofessional setting of the OR. The nurse asks if the surgeon is not in the OR, perhaps to clarify why the resident is not asking the surgeon about arm positioning. 2016 Jun 22;30(43):42-6. doi: 10.7748/ns.2016.e10513. In the example of the surgical pause, the nurses speak quietly despite having institutional authority. Nurs Stand. Well, they’ve taken out her colon so technically she doesn’t have it anymore. Over 700 surgical procedures were observed from 2005–2007. Nurses often feel constrained in what they are able to say in the operating room, or feel that they are a passive audience for others. Disruptive behaviour in the perioperative setting: a contemporary reviewLes comportements perturbateurs dans le contexte périopératoire: un compte rendu contemporain. Commentary: Communication: The Most Important “Procedure” in Healthcare and Bioethics. This example displays two recurrent issues in the data set. NIH The surgeon notices this and says, ‘Just tell me it’s up’ and then ‘We’ll try to remember to pass it back to you’. Pre‐op diagnosis is small bowel obstruction’. Exploring the Unspoken Dimensions of Complex and Challenging Surgical Situations. Nurs Stand. Many nursing organizations, nursing schools, hospitals, and other health care institutions have PR, marketing, or communication specialists working for them. In this paper, we report on data gathered as part of a multi‐site study of interprofessional communication in the OR.  |  The scrub nurse with scalpel in hand, and therefore the surgeon’s attention, says again, ‘The surgical pause’. Silence has not been fully appreciated in qualitative research, despite an increased awareness of its significance in communication. We observed something similar in terms of nurses often speaking to other nurses when trying to resolve a problem rather than approaching surgeons, even when the issue was one that could be resolved more directly by asking a member of the surgical team. Intermediate Neurodynamic Representations. Researchers in the fields of sociolinguists and feminist anthropology have explored the strategic use of silence. The nurse’s doubtful tone and raised eyebrows suggest that she is not entirely convinced. 2016 Jun 8;30(41):36-8. doi: 10.7748/ns.30.41.36.s43. Research suggests that inadequate communication is a primary cause of medical errors and that communication among the professions in the operating room (OR) is essential to patient safety (Gawande et al. Nurs Stand. However, we observed a distinctive patterning of irresolution with regard to nurses’ speech acts. 2016 Apr 20;30(34):36-8. doi: 10.7748/ns.30.34.36.s45. Apply this article to your practice. Effective communication skills in nursing practice Elaine Bramhall Managing director, consultant and trainer, Effective Communication Matters, Manchester, England This article highlights the importance of effective communication skills for nurses. If Standard ethnographic techniques for writing field notes were used (Hammersley & Atkinson 2007). and you may need to create a new Wiley Online Library account. The nurses in the following excerpt appear uncertain about how to act on a surgical request, but also hesitate to voice the need for clarification: A surgical resident asks for the cautery to be set at ‘60 spray mode’. For example, it can reveal itself when staff do not seek clarification, ask follow‐up questions, or communicate immediately relevant information. The anesthesiologist is still talking to the surgeon. Theories of silence and power suggest that silence is not a straightforward reflection of powerlessness; it may also be used strategically, for example, as a means of exerting power or resisting power. Nurse/Physician Communication Through a Sensemaking Lens. A nurse with good communication skill is someone who really listens to the patients, understands their problems and queries and answers in a way the patients will understand. The focus here is on constrained communication: on why an OR professional may remain silent when something of concern takes place. There are multiple forms of problematic silences in the operating room, including the absence of communication, non‐response to a colleague’s question or request, and quiet or hesitant speech. Please enable it to take advantage of the complete set of features! We observed nurses using a laconic style to influence the behaviour of others, to chastise, or to encourage events in the OR to flow the way they wanted them to. Even when silent, we transmit messages – deliberately and accidentally. The silence we observed in the OR often took the form of non‐responses to direct questions or requests. The communicative constraints on nurses have been analysed in terms of the ways that knowledge and competence are displayed in the ‘theatre’ of the OR (Riley & Manias 2005, Gillespie et al. Application of photogrammetry to generate quantitative geobody data in ephemeral fluvial systems. Nursing and anaesthesia trainees, and respiratory therapists, were periodically present as well. It is not clear what the nurse’s reasons were for not wanting to tell the surgeon that the instrument was ‘up’. USA.gov. Silence, used in the appropriate way, can help you and the other Nurses often try to resolve problems in a ‘back stage’ manner, at times, no doubt, to avoid bothering surgeons, but at other times to avoid revealing uncertainties and appearing inadequate. They consult each other, but do not report their uncertainty to, or seek clarification from, the surgeons. : Use the link below to share a full-text version of this article with your friends and colleagues. Methods. We don’t know what we’re going to do. Actually, silence can be used as an effective communication … No answer from nurse. Factors that affect scrub practitioner non-technical skills: a qualitative analysis. Concerns About Verbal Communication in the Operating Room: A Field Study. LL supervised the study. One researcher (FG) further analysed these instances categorizing them into three predominant forms of silence. 2015 17th International Conference on E-health Networking, Application & Services (HealthCom). Language matters: towards an understanding of silence and humour in medical education. Communication for nurses is important in the present situation, and communication is an important part of the nursing practice, which has a special meaning. After the first two requests by the surgical resident, the nurses say nothing about being unable to locate the ‘spray mode’. This work has been submitted by a student. The anesthesiologist is chatting with the surgeon. How to inform relatives and loved ones of a patient's death. A circulating nurse changes the settings. Absence of communication is ‘observable’ when it can be deduced from situational factors. Yet, power dynamics often reveal themselves in communication over mundane and routine matters. OPUS Uluslararası Toplum Araştırmaları Dergisi. 2008). To the extent that it plays a role in the lack of success of a speech act, speaking quietly may be perceived as a symptom of the traditional view of silence as a passive or quiescent stance. 2004). There was a significant degree of rotating membership on the teams. silence operates in partnership with speech to support therapeutic communication. of effective nursing communication in clinical practice, a good understanding of what constitutes effective communication is helpful. Policies to promote safety in the operating room by encouraging team members to ‘speak up’ are important but cannot ignore how speech and silence interact and shape each other. 2019 Jun;35(3):310-314. doi: 10.1016/j.soncn.2019.04.013. Absence or presence: Silent discourse in the operating room and impact on surgical team action. The nurse appears to want further information from the surgeon, which he in turn appears reluctant to provide: The surgeon tells the two surgical residents to scrub while he preps the patient. OR teams were typically comprised of a surgeon, a scrub nurse, one to two circulating nurses, an anaesthesiologist or anaesthesia fellow, and two to three surgical trainees. Nurses also report seeing themselves as ‘keepers of the peace’ whose role is to maintain a calm environment for surgeons to focus on their work, sometimes described as a gendered role or a ‘female thing’ (Riley & Manias 2005). The circulating nurse records this diagnosis on the operative record. The effect of continuing professional education on perioperative nurses’ relationships with medical staff: findings from a qualitative study. The resident’s response (‘He’s in trouble?’) sounds somewhat provocative, a little as if he is saying, ‘What’s the problem?’ The nurse does not respond; yet, with minimal further communication, she manages to have him ask the surgeon for the information she wants. Working off-campus? In research on nurse–physician communication in settings such as ORs or ward rounds, nurses persistently report that they are perceived as a passive audience for others, and that they are constrained in what and when they are able to communicate (Manias & Street 2001, Lingard et al. The resident asks again for ‘spray mode’. The surgeon does not provide the nurse with details about the type of prep solution that he used, only reaffirming that the patient had been prepped. 2008). » It is important that nurses are able to respond therapeutically to rhetorical statements and/or those concerning serious or severe clinical circumstances. We noticed how we, as observers, would pick up on these constructions of nurses at times in our field notes: for example, a nurse who asked a surgeon to change his gloves several times before he complied was described as being ‘agitated’. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. Rationale and key points This article explains intentional silence, which can provide a therapeutic nursing presence that demonstrates compassion and respect for the patient. COVID-19 is an emerging, rapidly evolving situation. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. “Disruptive behavior” in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams. This research was funded by the Canadian Institutes of Health Research (CIHR), reference number 57796. How we approach and train for interprofessional collaboration should incorporate an awareness of the complex strategies and modalities of communication, including silence, employed in the operating room setting. From a critical perspective, we understand our field notes and observational interpretations to be ‘texts’. An evaluation of perioperative communication in the operating room. Also, while we often recorded the volume of speech when it was ‘quiet’, we were less likely to describe someone as speaking ‘loudly’. For example, most nurses were not assigned to work with the same surgeon all the time, and anaesthesiologists worked in multiple services. Communication is simply about conveying a message, and sometimes silence … Furthermore, we suggest that silence is reflective of power dynamics and can help in understanding when, where and why communication is constrained. There are many skills that are known to be of importance to nurses and one of the main ones is that they require to have great communication … There is another short pause before the resident says, ‘Oh, what do you want to know about his guy? The circulating and scrub nurses examine the cautery machine. 2007). An interview study to identify scrub nurses’ non-technical skills. Many silences in the operating room derive from fear of appearing inadequate or incompetent in front of other operating room professions.  |  We observed instances of surgeons describing a nurse who was actively monitoring sterility in the OR as a ‘drill sergeant’, or joking about nurses ‘losing it’. Non-verbal communication can contradict the spoken word and the ability to recognise these non-verbal cues is vitally important in nursing practice (McCabe 2006), for example, a patient may verbally communicate that they are not in pain, but their non-verbal communication such as facial expression may indicate otherwise. In the first instance, the nurse asks twice about the preoperative diagnosis and gets no response; in the second, the surgeons do not respond to five requests about whether they want a Belfour retractor. The research was undertaken in general surgery at three tertiary‐care hospitals in Toronto, Canada. The data presented here are taken from instances of interprofessional communication in field notes that were coded by one of four trained observers as being characterized by unresolved or unarticulated issues. Silence may reflect powerlessness, but at times may also be a form of expression used by nurses and other operating room professionals to accomplish objectives. Therefore, explicit attention to silence may be seen as a way of attending to the voices of those with less power. The aim of the study was to explore whether a 1‐ to 3‐minute preoperative interprofessional team briefing with a structured checklist was an effective way to support communication in the OR. » The nurse can use intentional silence to support the patient in acknowledging, processing and reflecting on changes in their health. We conducted a retrospective study of silences observed in communication between nurses and surgeons in a multi‐site observational study of interprofessional communication in the operating room. FG, LL and SW performed the data analysis. The nurses’ speech act in requesting or reminding the surgeon to complete the surgical pause is somewhat ineffectual in terms of occasioning a complete pause. » Intentional silence can be used to reduce the patient's emotional lability by ensuring that they feel listened to. As Riley and Manias (2005) suggest, concern about betraying a lack of knowledge may encourage a self‐protective silence; being reprimanded for not knowing a surgeon’s preferences, for example, was a common experience for nurses in their study. Many of the instances we recorded of nurses having difficulty in obtaining responses or effecting action relate to brief, seemingly mundane, skirmishes that occur in domains of nursing responsibility, including monitoring sterility in the OR, the instrument count and the surgical pause. Riley and Manias describe the effort nurses will often put into maintaining an outward appearance of competence in the OR as ‘front stage’ behaviour for a surgeon audience. The Relationship between Continuing Professional Education and Horizontal Violence in Perioperative Practice. We may not do anything. Surgical resident says he does not know, but will ask, and then leaves the room. Low Level Predictors of Team Dynamics: A Neurodynamic Approach. Furthermore, our analysis points not only to how individuals exercise power in the OR setting, but also to social and structural aspects of power; for example, silences may reflect predispositions or internalized factors resulting from broader institutional power relations. 2016 Sep 14;31(3):42-46. doi: 10.7748/ns.2016.e10542. Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username, I have read and accept the Wiley Online Library Terms and Conditions of Use, Power and empowerment in nursing: a fourth theoretical approach, Edgework: Critical Essays on Knowledge and Politics, Excitable Speech: A Politics of the Performative, Power and conflict in intensive care clinical decision making, Interpretive Ethnography: Ethnographic Practices for the 21st Century, Between speech and silence: the problematics of research on language and gender, Gender at the Crossroads of Knowledge: Feminist Anthropology in the Postmodern Era, Fumbled handoffs: one dropped ball after another, Analysis of errors reported by surgeons at three teaching hospitals, Operating theatre culture: implications for nurse retention, The Presentation of Self in Everyday Life, Introduction: critical perspectives in organizational control, Joint Commission on Accreditation of Healthcare Organizations, Power and empowerment in nursing: three theoretical approaches. Survey research on team communication in the OR indicates that nurses and anaesthesiologists have less positive perceptions of the effectiveness of their communication compared with surgeons, and are less likely to respond positively to the statement ‘I am comfortable intervening in a procedure if I have concerns about what is occurring’ (Mills et al. Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad. Silence may be a means of exerting power over others, a reflection of relative powerlessness or a means of resisting power. Nurs Stand. Healthcare Teams Neurodynamically Reorganize When Resolving Uncertainty. The following example illustrates both the ‘quiet’ volume of the nurses’ speech and the unresolved nature of the nurses’ speech acts. Human Factors: The Journal of the Human Factors and Ergonomics Society. We did not set out to record silences in OR communication. She goes to the controls and adjusts them. He’s an accomplished individual but rather quiet and reserved by nature. 35-45. Keywords: Subscribers can upload their reflective accounts at rcni.com/portfolio. Surgical resident: ‘I’ll ask [surgeon]. Non-verbal communication: the importance of listening. The silence may allow one to become more open to new ideas or to think about matters more in-depth. This is not to say that discursive projects do not create silences and silencing processes, but silences may also ‘function as that which discourse has not penetrated, as a scene of practices that escape the regulatory functions of discourse’ (Brown 2005, p. 88). We will explore this further in the next section. We identified three forms of recurring ‘silences’: absence of communication; not responding to queries or requests; and speaking quietly. Silence is an important communication tool. The capacity to bear witness and respond empathically to a dying person’s suffering is inherent in end-of-life care. 2007), the continued dominance of bio‐medical discourse over other types of healthcare discourse (Björnsdottir 2001, Coombs 2003), and the disempowered or ‘oppressed group’ status of nurses (Kuokkanen & Leino‐Kilpi 2000, Bradbury‐Jones et al. Nurse‐doctor interactions during critical care ward rounds, Toward a problematic of silence in action research, Teamwork and communication in surgical teams: implications for patient safety, Reading between the lines: interpreting silences in qualitative research, Rethinking theatre in modern operating rooms, Governance in operating room nursing: nurses’ knowledge of individual surgeons, Communication failures: an insidious contributor to medical mishaps. This strategy was characteristic of at least two nursing team leaders who were present for multiple observation sessions. 2003, Sutcliffe et al. Interprofessional learning: a student's perspective. If you do not receive an email within 10 minutes, your email address may not be registered, This paper is a report of a study conducted to explore whether a 1‐ to 3‐minute preoperative interprofessional team briefing with a structured checklist was an effective way to support communication in the operating room. Strategies for Reflexive Ethnography in the Smart Home: Autoethnography of Silence and Emotion. The nurse who stands when a patient enters a room and steps forward with a welcoming smile is in stark contrast to the colleague who remains behind a desk looking at the patient’s notes. In one example, the surgeon enters the OR, greets the patient and asks if he is nervous. Hiding in plain sight: communication theory in implementation science. Silence is a therapeutic communication technique that is also very helpful when the nurse wants to give the client ample time to fully and openly discuss their feelings, opinions and beliefs, however, prolonged silence may be Background. Instances of communication characterized by unresolved or unarticulated issues were identified in field notes and analysed from a critical ethnography perspective. The Use of Multiple Qualitative Methods to Characterize Communication Events Between Physicians and Nurses. Thus, in terms of their ability to communicate, or as modes of expression, neither silence nor speech is straightforwardly negative or positive. Because of their central role in patient safety and advocacy, nurses are often the subject denoted in questions about why no one spoke up. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features I’m not sure’. After examining constraint in naturally occurring communication, we suggest that there is a general reticence that pervades much nurse–physician communication in the OR. The scrub nurse and student nurse ask four more times over the next 15 seconds if the surgeons want the Belfour, but never loudly and they get no response. On collective self‐healing and traces: How can swarm intelligence help us think differently about team adaptation?. Observers continued to obtain signed consent from OR team members as the study progressed. Most importantly, why are some speakers hesitant, tense, reticent and not entirely audible, while others are confident, at ease, gregarious and perfectly audible, if not in fact loud? Two specific features of a critical approach inform our ethnography of silence: (1) attention to power dynamics in silence and (2) the usefulness of critical methodology for analysing silences. The surgical resident may not want to risk being contradicted by the colleague about the choice of retractor. Attention to the complexity of silence in the OR is also essential in the context of increasing movements in health care to ‘foster’ collaboration and ‘improve’ communication in clinical team settings. How’s that?’, Surgeon: ‘Oh good’. These examples illustrate how power and status hierarchies come into play in seemingly mundane communication surrounding the completion of routine tasks. The circulating nurse says, ‘All right’ but does not take any action. PMID: 7860345 [PubMed - indexed for Speaking up behaviours (safety voices) of healthcare workers: A metasynthesis of qualitative research studies. After the patient is anesthetized the surgical resident returns to the room and begins catheter insertion. Regardless, she does not appear to want to speak and the recurring exchange between surgeon and scrub nurse is difficult to explain in the context of what is happening at the time in the OR. This review seeks interdisciplinary experience to deepen understanding of qualities of silence as an element of care. The solution is clear and invisible when it dries on the patient’s skin. The surgical resident and surgical fellow are talking to each other and do not respond. Journal of Obstetric, Gynecologic, & Neonatal Nursing. A critical approach to silence emphasizes an awareness of the interplay between social structures and local context. FG and LL were responsible for the study conception and design. Similarly, Gal (1991) details research on varied forms of cultural expression adopted by women – genres of communication that are at times veiled, ambiguous, laconic or indirect – which, on the surface, may be perceived as silent and inarticulate, but which may also be ways of asserting one’s own power or resisting that of another. A surgeon participating in our study identified this type of behaviour as a defensive rather than assertive posture, linking the opposition of some surgeons to preoperative communication protocols to an insecure stance in relation to a slowly eroding notion of surgeon autonomy and an emerging conception of surgeons as part of a ‘team’. In the example below, the nurse uses a combination of minimal words and direct action to obtain a response from a resident who is putting off her requests for information: After the patient has arrived in the OR, the anesthesiologist asks the surgical resident if the surgical team will want the patient’s arms to be tucked in for the surgery. These complexities underline the importance of examining the context of communication – not just the immediate local and individual context, but larger institutional, cultural and structural contexts – to understand the meaning of silence (Gal 1991, Poland & Pederson 1998). Participants in the study were 11 general surgeons and all members of OR teams working in those surgeons’ ORs, including 116 OR nurses and 74 anaesthesiologists. The instances we examine do not all relate to issues of patient safety; many are much more mundane exchanges. Purpose of the role of silence and voice: the practices of informing in nurse-physician interaction a light. This diagnosis on the teams further analysed these instances categorizing them into three predominant of! Up, ’ but does not say anything but goes to the dynamics of silence and for. Time she reaches for it instead silence and quiet can play useful roles in the theatre... A prospective observational study of interprofessional communication about the patient to educate your colleagues think differently about team adaptation.. Begins catheter insertion with physicians ethnographic techniques for writing field notes were used ( Hammersley & Atkinson )! The choice of retractor other it is important that nurses adopt changes in their.... And then leaves silence in communication nursing room and begins catheter insertion instances we examine are! Recognize Neural Correlates of team dynamics: a randomized controlled trial and communication Continents. Taken out her colon so technically she doesn ’ t have a retractor. 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