VOL: 100, ISSUE: 14, PAGE NO: 42
Sue Saunders, BSc, RGN, is staff nurse, the Royal Bournemouth Hospital
Traditionally, the theatre nurse’s role was not considered by many to be conducive to the development of good communication skills. Mardell and Rees (1998), for example, suggest that theatre nursing has been associated with mechanistic interventions on patients who are in no position to respond to, or interact with, the nurse. Instead of being at the beck and call of patients, like colleagues in other clinical areas, the theatre nurse’s main role was seen as providing support for the surgeon and the anaesthetist.
However, excellent communication skills have become paramount with the development of the perioperative nurse. Together with government initiatives such as The NHS Plan (Department of Health, 2000) and Essence of Care (DoH, 2001), which focus on the need to get the fundamental aspects of nursing right, this places a new emphasis on the philosophy that underpins the work of the theatre nurse. Today theatre nurses are required to have a holistic, truly patient-centred approach to care before, during and after the patient’s surgical experience (Rees, 1999). Good communication with patients, theatre colleagues, and other departments is a key element.
With an ageing population and the associated risks of general anaesthesia, more surgical procedures are being carried out under local or regional anaesthetic. The patients remain conscious throughout such operations and this has required theatre nurses to keep in close contact with those who may be feeling anxious and vulnerable (Mardell and Rees, 1998; Walker, 1998). Extended roles for theatre nurses, such as surgeon’s assistant and carrying out minor operations, are common therefore increasing the need for nurses to provide preoperative and postoperative information and health advice. The provision of postoperative information and advice will lessen patients’ anxiety and feelings of vulnerability.
Defining effective communication
Communication is the essence of social interaction, yet despite its significance Hargie et al (1994) suggest that a precise definition is notoriously difficult. At its simplest, communication may be defined as a means to ‘transmit or pass on by speaking or writing’ or to ‘impart or share feelings non-verbally’. But to be effective it must ‘succeed in conveying information and evoking understanding’ (Allen, 1991).
Communication generally requires a sender, a messenger, a receiver, and a channel of communication. Hargie et al (1994) remind us that the words or language used play only a small part in conveying any message. Meaning is also communicated by the following:
- Tone of voice, intonation, speed, and volume;
- Posture, body movements, and gestures;
- Facial expressions;
- Use of touch.
Environmental factors such as choice of furniture, smells and noise are also influential on the outcome of interpersonal relationships. Active listening and questioning skills are as important as appropriate language. The personal characteristics of the participants sharing a situation contribute to shape the interaction and determine whether the information is successfully passed on.
Communicating with patients
Good communication ranks equally with technical competence in theatre and it is therefore enjoying an increasingly high profile across many areas of the Royal College of Surgeons of England’s work (RCS, 2003). The RCS’ clinical guidelines for surgeons regarding communication provide an excellent grounding for all staff involved in perioperative care (Box 1).
The RCS also recognises that an important role of the surgeon is as an educator (RCS, 2003). Westwood (2001) asserts that patients now want to be part of the decision-making process and are entitled to receive accurate information. They are now also much more likely to challenge what health care professionals say to them than they were in the past.
It is a legal requirement of informed consent that a patient (or the patient’s parent or guardian) must be provided with sufficient information before agreeing to surgery. This includes disclosing significant risks and describing alternative management (Bates, 2001).
Ideally the operating surgeon should be involved and the patient should have ample opportunity to discuss concerns in advance of admission. But consent is often delayed until the day of surgery when the patient may be feeling stressed and vulnerable. So in reality it is nursing staff who may be asked to explain the surgical procedure and pick up on cues from the patient regarding aspects of care she or he may wish to be clarified.
Westwood (2001) and Taylor and Campbell (1999a) agree that open questions should be used to establish how much the patient understands and how she or he is feeling. It is important to listen attentively to patients. Patient information leaflets are useful as an aid to communication and encourage the patient to ask questions (RCS, 2003).
James (2000) asserts that having an operation is always a cause for some anxiety and fear for most people. Oliver (1999) highlights the numerous causes for concern for the perioperative patient, including:
- Expectation of pain and/or risk of disfigurement;
- Unknown routines;
- Loss of control;
- Separation from family and friends;
- Unknown prognosis.
It is recognised that stress and anxiety can produce an imbalance in the body’s natural homeostasis. This can lead to an increased cardiac workload and suppression of the immune system (Gross, 1996). Such changes are detrimental to postoperative recovery and should therefore be minimised.
Patients are often most nervous immediately before the administration of the anaesthetic. At this time, noise levels should be kept to a minimum, all stages of the process should be explained to the patient and reassurance given. For patients undergoing surgery under local anaesthetic, music can be used to aid relaxation (Oliver, 1999).
The use of appropriate touch, such as a comforting touch on the arm, can sometimes be rewarding, giving encouragement during anxious moments.
Styles of speech should be adapted to allow for possible hearing difficulties or language differences. In an increasingly multicultural society the use of interpreters may be useful. Sometimes adaptation of speech styles, such as speaking slowly, using short words, avoiding jargon, and using simple grammatical constructions is sufficient to aid understanding (Hogg and Vaughan, 1995). Often there are facial expressions, gestures and postures that can cross international barriers (Box 2).
Communicating with other staff
Bonnington (1994) asserts that good teamwork provides the solid foundation for achievement and when taking into account the variety of staff making up the multidisciplinary team in an operating theatre it becomes apparent that effective communication is an essential skill. Hogg and Vaughan (1995) discuss the way in which individuals occupying different roles in a group need to coordinate their actions through communication, though not all roles need to communicate with each other.
The concept of efficient group performance using a communication network functioning around a ‘hub person’ relates well to an operating team. The scrub nurse is central to receive, integrate, and pass on information to and from the surgeon while allowing peripheral members to concentrate on their allotted tasks. Verbal communication is often hampered by surgical masks, which muffle speech. Eye contact and modifications of speech style should by made to ensure that the listener understands what is being said. This is important when there may be several team members for whom English is not their first language (Hogg and Vaughan, 1995).
Taylor and Campbell (1999a) explain that the interpretation of a message can differ for each recipient. The listener should respond through expressions and gestures, and check for non-verbal clues that confirm or contradict what is being said. Communication is a two-way process that requires clarification and reinforcement, and should be reflected back by repetition to confirm understanding.
The swab count between scrub nurse and circulator illustrates this perfectly. The count should be undertaken aloud, with both participants confirming numbers of swabs and sharps in use or discarded. A running total should be kept on a whiteboard in clear view of the scrub nurse to record the count. The scrub nurse is then able to confirm to the surgeon, when necessary, that nothing has been lost.
As a general rule, unnecessary noise and movement should be kept to a minimum as it can distract the operating team from concentrating. Any background music should be stopped when total concentration is required (Oliver, 1999; Taylor and Campbell, 1999a).
Written forms of communication are also useful as a one-off aid to communication or as a permanent record for different teams of staff using a theatre. The operating list, for example, provides a wealth of information about a patient in order to allow safe preparation for a planned operation and surgeons’ preference cards provide a permanent record of an individual surgeon’s requirements for set procedures so as to minimise delays (Box 3).
Bonnington (1994) explains that an atmosphere where the team as a whole is valued as well as the input of individuals contributes towards an attitude of optimism and trust, which will help to overcome problems. A study by Livesley (2000) found that the major factor causing unhappiness within an operating department was poor communication. The study recommended that team meetings, preferably weekly, should be undertaken to discuss problems, appraise staff, generate new ideas, and introduce changes in order to raise morale. Taylor and Campbell (1999b) agree that opportunities should be provided to debrief staff after difficult events.
Communicating with other departments
For an operating theatre to run smoothly, it is essential that there is clear communication and coordination between managers, surgeons, anaesthetists, preoperative assessment, wards, and bed managers.
Davidson (1999) identifies a need for improved communication links between ward staff and theatres. It is suggested that a named theatre nurse should act as a liaison nurse. This nurse would be the first point of contact for ward staff, addressing issues that may arise regarding perioperative care. The liaison nurse is ideally placed to be responsible for the booking of ward staff and/or students who wish to visit theatre. Such visits provide a useful insight into theatre business, and can be complemented by an explanatory handout.
Additionally, Davidson (1999) recommends that theatre staff become involved in preoperative visiting, so that the patients see a familiar face when they come in for treatment. This helps to minimise stress leading up to and during surgery. Simple gestures such as telephoning a ward 10 minutes before a patient is due to be collected or immediately when it is known that an operating order is to be changed, allow the final preparations of patients to be undertaken calmly and efficiently.
Patient care plans are a valuable source of information to be passed from one clinical area to another, and effort should be made by all staff to take ownership of the section relevant to their clinical area and to complete it comprehensively, accurately, and legibly. This will ensure safe continuity of care for the patient throughout the perioperative experience.
Overall planning and management should be directed by a theatre management group, for which one of the key roles is to analyse theatre utilisation and to anticipate problems that could arise. Relatively small steps, such as communicating when surgeons will be taking annual leave, help to reduce the need for operations to be cancelled (DoH, 2003).
Nurses should remember that any operation, from minor planned procedures to major emergency operations, is an anxious time for most patients. Good communication, especially the use of open questioning techniques and active listening with patients and their families or friends can help to address any fears and ease tensions, which in turn is beneficial to postoperative recovery.
This article has been double-blind peer-reviewed.