Silence, power and communication in the operating room

Fauzia Gardezi,Sarah Whyte,G Ross Baker,Lorelei Lingard,Sherry Espin,Beverley Orser

doi:10.1111/j.1365-2648.2009.04994.x

Abstract

Title. Silence, power and communication in the operating roomAimThis 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.BackgroundPrevious research suggests that nurses often feel constrained in their ability to communicate with physicians. 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.MethodsWe 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. Over 700 surgical procedures were observed from 2005–2007. Instances of communication characterized by unresolved or unarticulated issues were identified in field notes and analysed from a critical ethnography perspective.FindingsWe identified three forms of recurring ‘silences’: absence of communication; not responding to queries or requests; and speaking quietly. 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.ConclusionsThere is no single answer to the question of why ‘nobody said anything’. 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.

Highlights

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 2003, Sutcliffe et al 2004, Gandhi 2005, Joint Commission on Accreditation of Healthcare Organizations 2008)
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
We suggest that silence is reflective of power dynamics and can help in understanding when, where and why communication is constrained

Summary

Introduction

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 2003, Sutcliffe et al 2004, Gandhi 2005, Joint Commission on Accreditation of Healthcare Organizations 2008). 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 2004). Leaders of the different professions spoke to us about occasions when something of concern took place in the OR and ‘nobody said anything’. Because of their central role in patient safety and advocacy, nurses are often the subject denoted in questions about why no one spoke up. 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 be ways of asserting one’s own power or resisting that of another

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