The Guideline for Team Communication was approved by the AORN Guidelines Advisory Board and became effective January 15, 2018. It was presented as a proposed guideline for comments by members and others. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.
This document provides guidance for improving perioperative team communication through a culture of safety that incorporates team training, simulation training, standardized transfer of patient information (commonly referred to as hand overs or hand offs), briefings, time outs, surgical safety checklists, and debriefings. In 1999, the Institute of Medicine report To Err Is Human: Building a Safer Health System stated that between 44,000 and 98,000 hospital patients die annually as a result of medical errors in the United States.1 Subsequent studies have estimated the incidence to be as high as 180,000 to 400,000 deaths annually.2 Since this landmark report, the health care industry has embraced the need for change. Numerous organizations have written position statements on the importance of team communication and the use of a safe surgery checklist to reduce the incidence of medical errors.3-9
The collective evidence10-13 demonstrates that communication breakdowns in the perioperative setting are a factor in events that adversely affect patients. Seventy percent of adverse events in the surgical environment are caused by breakdowns in communication among health care providers.14,15 The perioperative environment is stressful, and perioperative team members are under increasing pressure from numerous demands and complex functions that lend themselves to error. Despite these pressures, patient safety is a top priority for perioperative RNs and cannot be sacrificed for efficiency. Communication tools and team training programs provide a foundation to improve the chances that communication is conveyed effectively and received accurately. The surgical safety checklist is one tool that the literature supports as improving communication in the perioperative environment.16-62 The use of checklists in hand overs, briefings, and debriefings provides a defense against adverse events.46,63,64
Successful perioperative team communication requires a high-reliability team with a shared goal. According to Wahr et al,50 high-reliability teams have six elements in common: communication, coordination, cooperation, cognition, conflict resolution, and coaching. An understanding by each team member of his or her role and responsibilities is necessary to achieve a successful surgical outcome for the patient. Beginning with the patient’s decision to consent to the procedure, valuable information is collected and handed over to multiple personnel during the patient’s surgical encounter. Effective communication among team members is important for understanding the surgical plan for each individual patient. A shared mental model increases the effectiveness of communication between team members because each team member is knowledgeable about his or her own role, other team members’ roles, and how these roles interrelate. As the surgery progresses, a shared mental model facilitates timely communication and response by each team member to changes in the surgical plan.50
Communication is a process that consists of sending and receiving messages; however, a variety of distractions can impede the ability to send or receive the message accurately. Distractions can be internal or external. Internal distractions are related to the individual’s nontechnical skills and individual resilience to human factors (eg, hunger, thirst, anxiety, anger, fatigue) when communicating within the team.65 External or environmental distractions can be divided into two types: essential and nonessential. Essential distractions come from components necessary for patient care, such as equipment alarms, telephones, pagers, and equipment noise. Nonessential distractions occur in the environment but are not necessary for patient care, such as irrelevant conversations, music, and interruptions from personnel not essential to the procedure. Hierarchical and personal relationships among the individuals on the team can be barriers to effective communication. Other individual barriers include educational background, language preference, culture, race, and gender.63
Interprofessional team members send and receive multiple messages throughout a patient’s surgical experience. Mohorek and Webb66 described the Linear Model of Communication as a conceptual framework for hand overs between physicians and described different reasons for errors during the hand-over process. Viewing the flow of communication in a linear model may be beneficial for mapping out the critical messages that are covered in each team conversation and for preventing repetition of information that is not critical.
Nontechnical skills, including situational awareness, decision making, leadership, communication, and teamwork, may affect team communications. Nontechnical skills have been extensively studied in aviation and have been added to training programs for pilots. Although tools for observing nontechnical skills have been validated for other professional roles in the perioperative setting, a standardized tool has not been developed for observing nontechnical skills in the perioperative registered nurse (RN) role. Validated tools for observing nontechnical skills in the perioperative environment include Observational Teamwork Assessment for Surgery (OATS),67,68 Anesthetist Non-Technical Skills (ANTS),69 Nontechnical Skills for Surgeons (NOTSS),14,70-72 and Scrub Practitioners’ List of Intraoperative Nontechnical Skills (SPLINTS).69
The following topics are outside the scope of this document: workplace violence, bullying, incivility, and workplace safety. Although disruptive behavior is mentioned in the description of the literature, guidance for addressing disruptive behavior is also outside the scope of this document.
A medical librarian conducted a systematic search of the databases Ovid MEDLINE®, EBSCO CINAHL®, Scopus®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from 2011 through April 2017. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until July 2017. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.
Search terms included subject headings such as operating rooms, communication, patient handoff, clinical protocols, intraoperative complications, interdisciplinary communication, hand off (patient safety), and Universal Protocol. Additional keywords and phrases included time-out, briefings, debriefings, passive, assertive, sentinel event, never event, TeamSTEPPS, system reliability, misinformation, miscommunication, and process improvement.
Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available (Figure 1).
Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.
Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author, a coauthor, and one evidence appraiser. The lead author divided the search results into topics and assigned the members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.
Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.
Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.
Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.
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