Team communication – a core non-technical skill

This is article sixteen in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

Florence the Great Dane had just come out of surgery, with Tom wiping the sweat from his brow after correcting her gastric dilatation and volvulus (GDV). James had assisted with the anaesthetic and was psyching himself up to deal with the aftermath; the prep room looked like a wrecking ball had gone through it. It was a skeleton bank holiday weekend crew, so Tom left James to look after Florence, while he went to start consults.

‘Hey James, the surgery went ok, can you keep an eye on Florence please, while I consult? She won’t be due any medications for another two hours, so just keep her on her current fluid rate.’

‘Sure thing,’ said James as he had just put Florence to bed and started to pick through the large pile of surgical instruments, always wary of any stray blade or needle mistakenly left behind.

After putting the instruments in for a soak, James checked Florence and managed to grab Tom in between consults. ‘Tom, her heart and respiratory rate are a bit higher, you may want to check her when you have a chance’. Tom thought to himself that Florence is probably just waking up said, ‘Be there in a bit’ and called in his next patient.

Two hours later, Tom was delighted to see that order had been restored to the prep room. When he went to check on Florence, his mood quickly changed. Florence was still lying on her side as he had left her, deteriorating in front of his eyes. 

‘What happened? Didn’t you watch her?’ 

‘Yes of course! I checked her a few times; you were busy with consults, and I was expecting you…’

Tom and James sprang into action to revive Florence, but after working for several hours, lost the fight.  They held a debrief and used the contributory factors checklist to grow their understanding of what happened in the lead up to the event and to identify areas for improvement. 

The value of clear language

While there is always more than one factor that contributes to an adverse event, Tom and James identified a major need to improve their communication. They felt they had always worked well together but realised that without a clear and concise exchange of information and establishing a shared understanding of the plan, there was too much room for different interpretations, which weakened the team and eventually led to patient harm. This is also reflected in human healthcare research that clearly shows many adverse events occurring in surgery relate to breakdowns in communication¹.  

In our example, the expectations weren’t clear about how often the patient should be checked or when to intervene. Equally, the ‘hint and hope’ method of expressing concern about a patient is fraught with risk².  

We naturally start to ‘hint and hope’ when we feel we are unable to speak directly and must defer to our colleague’s authority. However, authority is not bestowed by a job title or seniority, it is earned by building trust. When we trust our colleagues and feel safe to speak up in any situation, everyone has the confidence to ensure the safety of our patients.

“The single biggest problem with communication is the illusion that it has taken place.”

George Bernard Shaw, winner of the Nobel Prize for Literature in 1925, is credited with the quote above, but what exactly did he mean by it? It refers to the common situation where people exchange information and they think they understand what has been passed between them, when actually, their understanding is not the same. This is where the illusion that communication has taken place can be unsafe. 

Communication is more than just exchanging information, it is establishing a shared understanding, or a shared mental model, of what is going to happen next, so that patient care can be coordinated with the team.

Tools to foster clear communication between the team 

Closed loop communication

This enables the team to exchange concise information, clarify expectations, acknowledge that the information is received, and confirm that it’s understood. For example,

Tom: Please can you take Florence’s vitals every 15 minutes until I return from consults.  If the parameters are outside of the expected, ‘x’, let me know immediately. 

James: Yes, I will take her vitals every 15 minutes and will immediately let you know if they are outside of ‘x’. 

Speaking up and assertiveness

Failure to speak up, can have a negative impact on patient outcomes and quality of care. However, it may not always be easy for someone to do so. Junior team members may not feel able to speak up or make a request to a senior team member, additionally, senior staff may be unaware of this.  Team members may feel reluctant to speak up for fear that their ideas will be discounted, they may appear incompetent, or they may worry about offending a colleague. However, people are more willing to speak up if we create a culture where this is encouraged; we are of course talking about psychological safety. 

Equally, it is helpful to agree as a team on the kind of language that is acceptable to use in these cases.  While there are several models to choose from, a memorable mnemonic for escalating a concern is CUSS:

C:  I am concerned
U:  I am uncomfortable
S:  This has become a serious situation
S:  This procedure needs to stop

In our example, James could have used CUSS to demonstrate his growing concern for Florence, as his initial concern was not acknowledged:

‘This has become a serious situation. I need you to please stop what you are doing and examine Florence now.’

The ability to get everyone to stop and listen is essential for safe care. Using a communication model that we can agree on in advance, helps us avoid using the ‘hint and hope’ model of raising our concern and softens the edges when using concise language, as we know it is coming from a place of care, not criticism.

SBAR(D) 

SBAR stands for:

S:  situation – what is going on with the patient?
B:  background – what is the clinical background or context?
A:  assessment – what do I think the problem is?
R:  recommendation – what would I do to correct it?  What do you want to happen next?
+/- D:  decision – what are we going to do and who is going to do it?  This step may or may not be needed depending on the context of use.

In our example:

• Situation: I am concerned about Florence who is not recovering from her surgery as expected.
• Background: Her heart and respiratory rates have increased, and I detect an arrhythmia. 
• Assessment: I am concerned about her heart function and analgesia levels. 
• Recommendation: I need you to see her right now.

When SBAR is used, critically important pieces of information are given in a predictable way, in a structured approach that also helps people develop critical thinking skills. The person asking for help knows that before they contact their colleague, they must assess the problem and provide an appropriate solution. Their proposal may not be the correct answer, but there is value in defining the issue. SBAR can be used for a wide variety of contexts, including case handover and clinical rounds.

However, it is worth mentioning that we may not always be able to put our finger on why we have a concern, but we should voice it anyway. An Australian study demonstrated a reduction of in-hospital cardiac arrests of 65% through early intervention, the number one reason to call for help was ‘a staff member is worried about the patient’. While we may not always be able to put a concise label on what’s happening with the patient, our prior experience tells us that something is wrong, and help is needed. Making it acceptable for anyone to say ‘Something is wrong, I’m not sure what it is, but I need you here now’ is an effective mechanism to ensure safety. When we can couple this with SBAR, communication becomes progressively clearer. 

Other things you can try

Other tools, that have been covered in previous articles, can improve communication include team huddles – these tools include briefs and debriefs, and using checklists.

Making a difference

You want to improve communication within your team. How do you start and how will you know that you are making a difference? Start as you would with any clinical audit. Find out where you are now, so you know where you need to go. 

Ask your team, ‘Are communication breakdowns common?’ with an answer from, strongly agree, agree, neither, disagree or strongly disagree. Once you have implemented one or more of these communication tools, survey again over multiple time periods to see if you are making progress. Use this time to make sense of all results by asking the team why you have the results that you do. If you would like to go into greater depth and learn more about the patient safety culture in your practice, use the Nottingham Veterinary Safety Culture Survey³.  

Back to non-technical skills

As a profession, we have historically concentrated on developing our communication skills with clients.  This is vitally important as this skill helps us to be better advocates for the animals in our care. However, it is important to expand this further. Communicating effectively with our team leads to a heightened awareness of what is happening with our patients, a stronger team and better decision-making. Practicing these non-technical skills can result in a team that is building trust and understanding; solving problems together, leading to better patient care and taking more joy in our work.

Checklist: What you can do next?

• Have a look at the free to access QI Boxset Series 2: Clinical Audit, take the course at your own pace and learn why audits are beneficial to teams, clients and animals, and how to conduct them.  
• Access the free course to take at your own pace on Significant Event Audit in practice, learn how to break down the steps from start to finish in order to reflect and learn from an event to improve quality of care.   
• Have a look at this quick how-to guide for conducting significant event audits. 
• Download a handy template to record the results of the significant event audit.  
• Listen to Alice Bird from the Animal Health Trust as she talks us through how a significant event audit was conducted following a post operative complication that occurred in equine practice, including how a blame culture was avoided, the lessons learned, and the resultant processes put in place. 
• Read our previous QI Feature Building a safety culture in practice - a whole team approach for tips on how to adopt a safety culture and implement changes for continuous improvement. 
• Have a look at this Root cause analysis case example and download the free Contributory factors checklist template to help you identify the root cause of a problem, so you can take measures to prevent the event from happening again 
• Listen to Lizzie Lockett, Chief Executive Officer at the Royal College of Veterinary Surgeons, talk about Improvement not disapproval: Quality Improvement in veterinary regulation for a personal take on why it’s important for all people in practice to be open to change. 
• Listen to Pam Mosedale, QI Clinical Lead at RCVS Knowledge, explain how and why we use checklists in veterinary practice 
• VetSafe is a free and anonymous incident reporting tool by the VDS to help us learn from our mistakes.
• Listen to the podcast, The power of the growth mindset: why certain habits of mind matter in clinical improvement, by Bill Lucas, Director of the Centre for Real-World Learning & Professor of Learning at the University of Winchester, to see how you can cultivate habits of mind for a culture of continuous improvement for yourself and your team. 

References:

1.      Flin, R., Youngson, G. and Yule, S. (2016) Enhancing surgical performance: a primer in non-technical skills. Boca Raton: CRC Press

2.      Leonard, M., Graham, S. and Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care.  BMJ Quality & Safety, 13 (1), pp. i85-i90. http://dx.doi.org/10.1136/qshc.2004.010033 [Accessed 2 February 2022]

3.      Oxtoby, C. et al. (2017) Safety culture: the Nottingham Veterinary Safety Culture Survey (NVSCS). Veterinary Record, 180 (19), pp. 472 https://doi.org/10.1136/vr.104215

About the author

Angela Rayner BVM&S PgDipPSHCF MRCVS

Angela is a Quality Improvement Advisor for RCVS Knowledge, Director of Quality Improvement for CVS, and is an RCVS Knowledge Champion for her role in improving CVS’ systems for controlled drugs auditing.

In 2021, Angela completed a MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh. The programme supports healthcare professionals in using evidence-based tools and techniques to improve the reliability and safety of healthcare systems.

It includes how good teamwork influences patient outcomes, key concepts around learning from adverse events and teaching safety, understanding the speciality of clinical human factors, as well as the concept of implementing, observing and measuring change, monitoring for safety, and it focusses on quality improvement research and methodologies.   

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