Shared Cognition: Reflecting, Considering, Deliberating
Article Outline
Thinking
Thinking is at the heart of the care we deliver to patients. We know a great deal—about the patient, the surgical team's needs, the anesthesia team's needs—and so it goes. If that information is not shared, however, it has little value. Communication in the OR must be accurate, open, and effective if it is to contribute to the goal of safe patient care.
In the article on preoperative briefing, a cognitive model was defined as “the knowledge that a performer holds that helps in understanding what is going on in a certain situation, including tasks, goals, objectives, and requirements.”2(p444) The authors noted that such a model can facilitate planning, anticipation, and teamwork. For a complex surgical procedure, there are certain high-risk activities that will take place almost always. The nurse may reflect on the blood work that might be done during the procedure and how best to communicate the results to the surgical team, might consider potential difficulties with the count, or possibly deliberate about how to coordinate the numerous medications that will be delivered to the sterile field during the procedure. These cognitive activities (ie, reflecting, considering, deliberating) play but a small part in the complexity of perioperative patient care. Each of these activities requires the perioperative nurse to think. The perioperative nurse may, in fact, be the leader in interdisciplinary thinking about what is to transpire during surgery. The surgeon and anesthesia care provider each have a more limited and focused perspective and goal. The perioperative nurse simultaneously focuses on those perspectives and goals as well as numerous other considerations all within a limited period of time. Thus, the nurse plays a key role in improving outcomes and preventing adverse events for surgical patients.
Reflecting
When reflecting on blood work that might be done, the nurse knows how important communication of the results is. The nurse understands what a critical or significantly abnormal test result is and what his or her responsibilities are in receiving those results. If the results are called in to the OR from the laboratory, then the information must be written down and read back to the individual providing the information. The patient's name should be part of the read-back to be sure the laboratory test is being reported for the correct person. For full accuracy, the nurse may also record the date and time of the call and the full names of both parties.3
Considering
When considering potential difficulties with the count, the nurse first takes into account the institution's protocol for counts: when they are to be done, what needs to be counted, how the count is conducted (eg, sterile field to off-the-field, off-the-field to sterile field, sponge counting system) and how the count is documented. The nurse also considers whether the patient is at high risk for retention of a foreign body.4 Is this an emergency procedure? Was there an unexpected change in the planned procedure? Does the patient have a high mean body mass index? Is more than one procedure going to be performed simultaneously? Will there be a hand off for breaks or a change of shift? What will be done if the count is incorrect?
Deliberating
When deliberating about the numerous medications that will be delivered to the sterile field during the procedure, the perioperative nurse always considers the “rights” of medication administration: the right medication, right patient, right dose, right time, right route, right reason, right label, right announcement during hand off to and from team members, and right documentation. Moreover, he or she knows the importance of not being interrupted while preparing and delivering medications to the sterile field. In a recent study, Westbrook et al5 noted that each interruption during medication administration resulted in a 12.1% increase in procedure failures (eg, failure to read the label, check patient identification, record the medication) and a 12.7% increase in clinical errors (eg, medication type, dose, route, timing). Westbrook and her colleagues also noted, “Experimental studies suggest that interruptions produce negative impacts on memory by requiring individuals to switch attention from one task to another. Returning to a disrupted task requires completion of the interrupting task and then regaining the context of the original task.”5(p683) Thus, the perioperative nurse deliberates about the numerous medications that will be delivered to the sterile field, thinking not only about all of the “rights” of medication administration but also about preparing the medications without interruptions.
Extrapolating Knowledge
Perioperative nurses oversee seemingly simple activities such as communicating laboratory test results, performing counts, and managing medications multiple times every day. An observer might not perceive that there was much “thinking” going on, but there is. For each activity, the nurse has knowledge that helps in understanding the situation and what the tasks, goals, objectives, and requirements of the activity are. It is the extrapolation of that knowledge out of their heads and into the task that allows perioperative nurses to facilitate planning, preparation, and teamwork with such élan.
The perioperative nurse renders quality across a significant domain of care: the processes of perioperative patient care delivery in the management of common conditions for which surgical patients are treated. Nurses consistently use information based on their knowledge of the patient, the planned surgical procedure, the potential for adverse events, and their clinical experience to identify opportunities to improve quality and reduce risks. The drive to improve that care demands that perioperative nurses think and share their thinking as part of shared cognition. I would like to believe that what that surgeon really meant to say was: “You are a fine thinker. I appreciate your being on our team. Oh, and by the way, I also appreciate your giving me what I needed and not what I asked for!”
References
- . Out of the Head and Into the Heart: Insights, Tips, Ideas, Recipes and the Law of Success to the Point. [English edition] Adligenswil, Switzerland: IP Verlag; 2005;
- Preoperative briefing in the operating room: shared cognition, teamwork, and patient safety. Chest. 2010;137(2):443–449
- . Eight questions for getting beyond “getting results”. [Editorial] Joint Comm J Qual Patient Saf. 2010;36(5):224–225
- . Risk factors for retained surgical instruments and sponges after surgery. N Engl J Med. 2003;348(3):229–235
- . Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690
Jane C. Rothrock, PhD, RN, CNOR, FAAN, is a professor and director, Perioperative Programs, Delaware County Community College, Media, PA. Dr Rothrock has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
PII: S0001-2092(10)00692-7
doi:10.1016/j.aorn.2010.06.009
© 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.
