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. Theories of the performative aspects of speech (Austin 1962, Bourdieu 1991, Butler 1997) help delineate what happens when nurses do speak. Our research supports the finding of other OR ethnographies that the need for nurses to demonstrate competence, often through the ability silently to anticipate surgeons’ needs and preferences, can impede interprofessional communication (Riley & Manias 2005, 2006, Gillespie et al. 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 … 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. Our research contributes to deepening the understanding of such silencing processes. 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). Consider the following example, in which the nurse does not fulfil the surgeon’s request because she is uncertain which controls to use. Whether it is through spoken word, written word, non … From a critical perspective, such examples indicate the necessity to theorize beyond the immediate situational context. 2019 Jun;35(3):310-314. doi: 10.1016/j.soncn.2019.04.013. Communication is said to be indispensable in the delivery of quality healthcare [4]. Exploring silences in relation to power suggests that there are multiple and complex ways that constrained communication is produced in the operating room, which are essential to understand in order to improve interprofessional communication and collaboration. We conducted information sessions with OR staff before beginning our research to explain the study and distribute consent forms. Standard ethnographic techniques for writing field notes were used (Hammersley & Atkinson 2007). NIH 2020 Sep 10;11:547067. doi: 10.3389/fpsyg.2020.547067. We have drawn on the studies of Gal (1991), Glenn (2004),and Brown (2005) to consider how nurses may find space within silence to achieve goals and objectives. Instead he’s placed them on a rubber mat on the patient’s chest. 2008). Previous research on silence and power suggests that silence is not only a reflection of powerlessness or passivity, and that silence and speech are not opposites, but closely interrelated. 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. Nurs Stand. Concerns About Verbal Communication in the Operating Room: A Field Study. 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. 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. Furthermore, we suggest that silence is reflective of power dynamics and can help in understanding when, where and why communication is constrained. Nurs Stand. In reality, though, silence can be a very effective communication tool. Surgical resident continues working on the patient. A partial surgical pause takes place, with the anaesthesia team confirming some information while surgical team members respond with sarcasm or non‐participation. While speech is often equated with an active stance of self‐determination and self‐expression, silence is typically viewed as an indication of self‐censorship, passivity or quiescence. Nurs Stand. Finally, part of the self‐awareness needed on the part of the ethnographer is that one’s position as an outsider in the research setting, requiring a roadmap to understand what one is seeing, can lead to a privileging of the empirically overt, such as that which is spoken, over underlying social relations (Bourdieu 1977). Training Machines to Recognize Neural Correlates of Team and Team Member Uncertainty. Two minutes later, the surgical resident says, ‘I guess you guys don’t have a Belfour?’. PMID: 7860345 [PubMed - indexed for Quantitative work demands, emotional demands, and cognitive stress symptoms in surgery nurses. Previous research on silence and power suggests that silence is not only a reflection of powerlessness or passivity, and that silence and speech are not opposites, but closely interrelated. Journal of Obstetric, Gynecologic, & Neonatal Nursing. There was a significant degree of rotating membership on the teams. The Use of Multiple Qualitative Methods to Characterize Communication Events Between Physicians and Nurses. Anesthesiologist: ‘No, she has ulcerative colitis. Even when silent, we transmit messages – deliberately and accidentally. The surgical resident repeats ‘pause’ but the surgeon is not paying attention, possibly ignoring, and the resident does not follow up.  |  Nurses often use forms of silence to achieve objectives and communicate. She leaves the room and several minutes later the surgeon asks if the light source has arrived. 2016 Sep 14;31(3):42-46. doi: 10.7748/ns.2016.e10542. Findings. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. The anesthesiologist is chatting with the surgeon. 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’. The scrub nurse with scalpel in hand, and therefore the surgeon’s attention, says again, ‘The surgical pause’. However, we observed a distinctive patterning of irresolution with regard to nurses’ speech acts. The focus of the research was the collection and analysis of data on interprofessional communication about the patient and the surgical procedure. Culture, Silence and Voice: The Implications for Patient Safety in the Operating Theatre. No conflict of interest has been declared by the authors. Absence of communication is ‘observable’ when it can be deduced from situational factors. SILENCE IS POWER With the caveat that power can always be abused, the effective use of silence can bestow many gifts, chief among them: The ability to … What’s Behind the Scenes? Is loud speech less evident to us because it appears natural; and are we as researchers attuned to the invisible processes of naturalization through which power operates? 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. Researchers in the fields of sociolinguists and feminist anthropology have explored the strategic use of silence. USA.gov. Absence or presence: Silent discourse in the operating room and impact on surgical team action. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. Disruptive behaviour in the perioperative setting: a contemporary reviewLes comportements perturbateurs dans le contexte périopératoire: un compte rendu contemporain. Communication involves the exchange of messages and is a process which all individuals participate in. Experience of Communication for Patient Safety by Perioperative Nurses. An evaluation of perioperative communication in the operating room. Using Goffman’s (1969) theatrical metaphors, Riley and Manias (2005) discuss this phenomenon in terms of shifts between ‘front’ and ‘back stage’ behaviour. To the extent that silence is revealing of dynamics of power and privilege, it is important to ‘listen’ to silence (Mazzei 2007). The nurse’s doubtful tone and raised eyebrows suggest that she is not entirely convinced. Evidence of communication, influence and behavioural norms in interprofessional teams: a realist synthesis. Mazzei (2007) suggests a view of silence that ‘places it not in opposition to speech, but that positions silent speech on a continuum with voiced speech’ (p. 633). Communication in nursing Disclaimer: This work has been submitted by a student. JONA: The Journal of Nursing Administration. From a critical perspective, we understand our field notes and observational interpretations to be ‘texts’. Two of the sites were large urban academic teaching hospitals and the third was a smaller combined teaching and community hospital. 35-45. Communication is simply about conveying a message, and sometimes silence … 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. Surgical Time‐Out: Driving Change Through Electronic Documentation. 2003, Sutcliffe et al. Levels of constraint in speech, including tension in speaking, self‐censorship and frequent self‐correction are aspects of an embodied sense of the (subordinate) place that one occupies in a social space (Bourdieu 1991). To date, there has been no research directly examining the speech practices, including silence, that are identified as constrained or problematic. Nurses were recorded as speaking quietly several times in the preceding field note excerpts. There is no strong emotion in the surgeon’s tone as he repeats the instruction over and over. A critical approach to silence emphasizes an awareness of the interplay between social structures and local context. She does not verbalize this uncertainty, even after two requests for her to perform an action: Surgeon asks for insufflation of the patient’s abdomen. Factors that affect scrub practitioner non-technical skills: A literature review. Nurse/Physician Communication Through a Sensemaking Lens. Semin Oncol Nurs. We give examples of these and discuss them in terms of dynamics of power within interprofessional communication. 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’. 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. 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. In this example, there is a pattern of lack of response to nurses’ questions evident through exchanges about two different topics occurring a few minutes apart. Understanding and Optimizing Tourniquet Use During Extremity Surgery. SILENCE IS POWER With the caveat that power can always be abused, the effective use of silence can bestow many gifts, chief among them: The ability to … There’s no further mention of the Belfour. Female Pelvic Medicine & Reconstructive Surgery. 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. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features This ethnography of silence contributes a more nuanced view of interprofessional communication to counter an often tacit assumption that communication proceeds only through explicit, cross‐checking, performative speech. She goes to the controls and adjusts them. Once she very quietly says, ‘Up,’ but the next time she reaches for it instead. Therefore, it may seem mysterious that nursing still ranks as the least Current Obstetrics and Gynecology Reports. Actually, silence can be used as an effective communication … The nurse still does not act. Teaching Machines to Recognize Neurodynamic Correlates of Team and Team Member Uncertainty. 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. 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. communication; intentional silence; non-verbal communication; person-centred care; therapeutic communication. Communication is the transfer of information between people. International Journal of Nursing Studies. Perioperative nurses’ experiences of communication in a multicultural operating theatre: A qualitative study. Commentary: Communication: The Most Important “Procedure” in Healthcare and Bioethics. Using observational data from a multi‐year study of interprofessional communication in three hospital ORs, our objective in this paper is to directly examine instances of silence and constraint in communicative exchanges in the OR using a critical ethnography approach. This coding was done for all field notes and reviewed for consistency of coding by at least two other researchers. 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. While silence and speech are underlined by power dynamics, the authority of speakers is somewhat variable and contingent, assigned through formal and official discourses but also through various, diffuse and tacit processes. 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. LL supervised the study. » The nurse can use intentional silence to support the patient in acknowledging, processing and reflecting on changes in their health. Thinking ahead of the surgeon. A nurse brings a new light source into the room but does not ask if it should be set up. Well, they’ve taken out her colon so technically she doesn’t have it anymore. 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. The research was undertaken in general surgery at three tertiary‐care hospitals in Toronto, Canada. of effective nursing communication in clinical practice, a good understanding of what constitutes effective communication is helpful. Preventable Surgical Harm in Gynecologic Oncology: Optimizing Quality and Patient Safety. FG and LL were responsible for the study conception and design. In the following exchange, a nurse wants to verify whether a patient has been ‘prepped’ (prepared) for surgery. Observers continued to obtain signed consent from OR team members as the study progressed. 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. 2016 Apr 20;30(34):36-8. doi: 10.7748/ns.30.34.36.s45. The first relates to the audibility of the nurses’ speech (‘The scrub nurse and student nurse ask four more times…but never loudly’). AORN Position Statement on RN First Assistants. In this example, the nurses try to initiate a pause before the surgery (The surgical pause is a common patient safety protocol in which OR team members review key details before a surgery commences, such as patient name, surgical procedure and site): Everyone is in place to begin the surgery. Examples include not sharing information that others do not possess or not providing follow‐up communication. 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). The nurses in the above example have institutionally sanctioned authority in initiating a surgical pause. Critical theory represents a wide‐ranging tradition that shares a critique of societal institutions and an invested approach to research for the purposes of positive action or change. 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. Application of photogrammetry to generate quantitative geobody data in ephemeral fluvial systems. As a caregiving practice, silence is perceived as particularly relevant in spiritual and existential dimensions of … Silence has not been fully appreciated in qualitative research, despite an increased awareness of its significance in communication. Resident asks surgeon about type of incision and then arm positioning. » It is important that nurses are able to respond therapeutically to rhetorical statements and/or those concerning serious or severe clinical circumstances. Therapeutic silence is an important part of effective communication. The Wilderness Solo Experience: A Unique Practice of Silence and Solitude for Personal Growth. The circulating nurse leaves the room and returns with a Belfour retractor. 2008). 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? Please check your email for instructions on resetting your password. Reflective activity 'How to' articles can help to update your practice and ensure it remains evidence based. How to inform relatives and loved ones of a patient's death. The Relationship between Continuing Professional Education and Horizontal Violence in Perioperative Practice. Just a Routine Operation: A Critical Discussion. 1, pp. If OR team members did not consent to observations, we did not record observations of interactions involving that OR team member. 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. Assessing distractors and teamwork during surgery: developing an event-based method for direct observation. This review seeks interdisciplinary experience to deepen understanding of qualities of silence as an element of care. Furthermore, the quiet and hesitant tone often evident in nurses’ speech may in part reflect (and reproduce) a social practice in which a nurse who speaks and acts assertively risks losing legitimacy. The silence in this example seems to demonstrate what poststructural theorists have long argued is the most subtle and effective form of power – not the ability to coerce, but power’s ability to produce and create; to shape subjectivities and conceptions of who we are. Extrapolating from current literature on the culture of silence in nursing (Buresh and Gordon 2013), this becomes a complex and politically charged question. [name], did you say that this patient has Crohn’s?’. 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. Pre‐op diagnosis is small bowel obstruction’. The anesthesiologist is still talking to the surgeon. Initiatives to encourage people to talk are important but cannot ignore the complexity of the spectrum of speech and silence, and how speech and silence interact and shape each other. As well as reflecting individual behaviours, silences may reflect predispositions or internalized factors resulting from broader institutionalized power relations. There is another short pause before the resident says, ‘Oh, what do you want to know about his guy? Ironically, people consider silence as the absence of communication. 10, no. Silence, used in the appropriate way, can help you and the other 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. 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. What we examine here are instances of non‐response that do not appear to be entirely attributable to such factors. 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. Strategies for Reflexive Ethnography in the Smart Home: Autoethnography of Silence and Emotion. silence operates in partnership with speech to support therapeutic communication. These examples illustrate how power and status hierarchies come into play in seemingly mundane communication surrounding the completion of routine tasks. Managing Communicative Challenges and Interactional Dilemma: Native Speakers’ Responses to Non-Native Speakers’ Lack of Understanding. How will the nurse be perceived by colleagues from his/her own and other professions? Interprofessional Teamwork for Health and Social Care, https://doi.org/10.1111/j.1365-2648.2009.04994.x, Joint Commission on Accreditation of Healthcare Organizations 2008, http://www.jointcommission.org/SentinelEvents/Statistics. 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. Rationale and key points This article explains intentional silence, which can provide a therapeutic nursing presence that demonstrates compassion and respect for the patient. The circulating and scrub nurses examine the cautery machine. He does not report back about arm positioning. Communication for nurses is important in the present situation, and communication is an important part of the nursing practice, which has a special meaning. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. If you do not receive an email within 10 minutes, your email address may not be registered, The silence may allow one to become more open to new ideas or to think about matters more in-depth. “Disruptive behavior” in the operating room: A prospective observational study of triggers and effects of tense communication episodes in surgical teams. Interprofessional learning: a student's perspective. This is understandable given the difficulty of documenting silences in communication and the traditionally marginal role of silence in qualitative research (Poland & Pederson 1998). Journal of Cognitive Engineering and Decision Making. 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’. » Intentional silence can be used to reduce the patient's emotional lability by ensuring that they feel listened to. This happens multiple times, however, with the scrub nurse stepping down and reaching and the surgeon repeating, ‘Just tell me it’s up!’ The scrub nurse looks sort of bewildered. 2016 Jun 22;30(43):42-6. doi: 10.7748/ns.2016.e10513. Language matters: towards an understanding of silence and humour in medical education. 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. Our findings have implications for policy and practice to promote safety in the OR. OPUS Uluslararası Toplum Araştırmaları Dergisi. 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 … Surgeon looks to scrub nurse, who hands the first instrument. COVID-19 is an emerging, rapidly evolving situation. Also, while we often recorded the volume of speech when it was ‘quiet’, we were less likely to describe someone as speaking ‘loudly’. 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. 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. A few seconds later the phone rings. Silence and quiet can play useful roles in the OR, and are necessary for the safe performance of some tasks. Speaking up behaviours (safety voices) of healthcare workers: A metasynthesis of qualitative research studies. The Nursing and Midwifery Council’s Code (NMC, 2015) identifies non-verbal communication as a tool, stating that nurses sh… Healthcare Teams Neurodynamically Reorganize When Resolving Uncertainty. Butler (1997) critiques what she refers to as Bourdieu’s static notion of authority, however. Does loud speech co‐create quiet speech? 2015 17th International Conference on E-health Networking, Application & Services (HealthCom). The Power of Silence in Effective Communication Generally speaking, eastern cultures value silence more than the use of words, while in western culture, sometimes the opposite is … Beyond “Communication Skills”: Research in Team Communication and Implications for Surgical Education. 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. Meanwhile, nurses may engage in ‘back stage’ behaviour, such as consulting with each other in hushed voices about a surgeon’s preferences, to avoid publicly appearing uncertain. Apply this article to your practice. Nursing skills are key to any job position that one is which will help them gain and learn hence acquiring upon the skills and characteristics needed to succeed on the job. Are necessary for the drafting of the Human factors: the practices of informing in nurse-physician.! ) to be entirely attributable to such factors Proof-of-Concept study when there is another short pause before resident... Degree of rotating membership on the patient and asks the surgeon enters the OR, and are necessary the... To ' articles can help to update your practice and ensure it remains evidence.... Eyebrows suggest that she is not a straightforward reflection of power dynamics and can communication. 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