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Stop, Look, Listen: Active Listening Skills Vital in the OR

Stop, Look, Listen: Active Listening Skills Vital in the OR

OR Today Magazine | October Cover Story | Stop, Look, Listen

by Don Sadler

The ability to listen well is one of the most important success factors in practically any job or career. But it’s especially critical in the perioperative setting, where communication failures — including poor listening — are a major contributing factor to errors that compromise patient safety.

So stated an article published in The AORN Journal, which concluded that listening is the most important skill for effective communication in the OR. “The perioperative environment is fast-paced and production-driven, and this creates the potential for communication breakdown. In addition to its effect on patient safety, the lack of skilled communication affects employee engagement, decision making, productivity, morale and retention,” the article stated.

Breakdowns in communication between surgeons, perioperative nurses and other OR team members can lead to surgical delays, errors in procedures and patient inconvenience, the article noted, with one-third of communication errors affecting OR system processes.


“Effective communication is vital to patient safety, and good listening skills are an important element of effective communication,” says Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC, Perioperative Nursing Specialist with the Association of periOperative Registered Nurses (AORN). “Active listening may result in fewer misunderstandings and communication errors in the OR.”

Research indicates that patient safety mishaps are often related to a delay or breakdown in communica- tion. Communication failures were the root cause of nearly two-thirds (65 percent) of sentinel events reported between 2004 and 2012, according to the Joint Commission. “It’s notable that communication failures most frequently occur between health care providers themselves, rather than between patients and health care providers,” Van Wicklin points out.

In addition, good communication also enhances the processes that are associated with efficient and seam- less teamwork, “which is so very important in the perioperative areas,” says Van Wicklin. These processes include what are sometimes referred to as the “six C’s” of teamwork:

OR Today Magazine | October Cover Story | Stop, Look, Listen

1. Communication — Includes both speaking and listening.

2. Coordination — Harmonizing the sequence and timing of actions.

3. Cooperation — Working together harmoniously with a common purpose.

4. Cognition — Sharing an understanding or a collective body of knowledge.

5. Coaching — Taking actions to increase or improve knowledge and skills of ourselves and others.

6. Conflict resolution — Resolving discrepancies or incompatibilities.


Improving communication between OR team members — perioperative nurses, surgical technologists, surgeons, physician assistants, RN first assistants, anesthesia professionals and ancillary health care personnel — can provide a number of potential benefits. These include improving the ability of the OR team to provide competent and efficient patient care, decreasing the uncertainty around surgical procedure requirements, promoting a greater sense of harmonious teamwork and helping to facilitate health care cost containment.

Of course, it’s not the sole responsibility of the perioperative nurse to strive to improve communication and listening in the OR. “Rather, all members of the perioperative team need to do whatever they can to try to improve communication among team members,” says Van Wicklin.

Similarly, there’s no single method to improving communication in the perioperative environment, she adds, “because communication failures are related to multiple factors.” These may include poor timing of messages, missing or incorrect information being conveyed, and information being directed to the wrong person. “As perioperative team members, we need to improve the way we both send and receive messages.” On the receiving/listening side, Van Wicklin offers the following suggestions:

  • Focus your attention on the speaker and the message. Mindful listening requires that you be fully present and pay careful attention to what others are saying — and not start mentally forming your own response or argument before they have finished speaking.
  • Face the speaker and make eye contact. These are key nonverbal actions that are critical to mindful listening and indicate to the speaker that you truly are paying attention. They often encourage speakers to engage more fully, elaborate on their ideas and express their thoughts more deeply.
  • Don’t interrupt. We were all taught this as children, but it’s surprising how often we break this simple rule of communication — and of sheer etiquette — as adults in the workplace, including in the OR.
  • Repeat what you think you heard back to the speaker and ask for confirmation and/or clarification. This can be helpful in complex communication scenarios and in fast-paced and potentially stressful and intense environments like the OR, where there may be many external obstacles to listening like noise and multiple conversations occurring at the same time. Remember that listening is an active, not a passive, process.
  • Understand and adapt to other team members’ communication styles and preferences.

People respond differently to different kinds of communication. It’s not always easy to pick up on these nuances — one-on-one training and role-playing exercises with other members of the perioperative team can help team members with this important communication skill.


A discussion paper published last fall by the UCD Geary Institute titled Non-Technical Skills (NTS) for Enhancing Patient Safety: Achievements and Future Directions noted that “recognition of the role that breakdowns in communication and teamwork play in patient safety incidents has led to a plethora of studies in the area of what has come to be widely known as non-technical skills (or NTS),” which include communication and listening skills.

“This has led to increasing interest in identifying, assessing, training and measuring non-technical skills,” notes the paper. “There is growing awareness that non-technical skills are essential for competent practice, and NTS have been incorporated into medical education and training programmes.”

According to the paper, NTS theory and practice has its roots in Crew Resource Management (CRM) techniques developed in aviation and later applied in other disciplines. Indeed, The AORN Journal article pointed out that some experts have recommended that OR teams use CRM, along with structured checklists (like the World Health Organization Surgical Safety Checklist) and time-outs, to help standardize communication in the OR and increase patient safety. “These address unintentional events that result in communication breakdown.”

American Anesthesiology has implemented an innovative Patient Safety Initiative in its Atlanta-based practice that is based on aviation’s tested CRM training. According to Dr. Jeff Shapiro, medical director of American Anesthesiology’s practice at Piedmont Atlanta Hospital, this initiative is a critical step in improving patient outcomes by helping ensure that a culture of safety exists throughout the entire perioperative process.

“It encompasses the same principles found in High Reliability Organizations (or HROs) like the aerospace and aviation industries,” Shapiro says. “Crew resource management uses teamwork, communication, clearly defined roles, situational awareness, debriefing, checklists and permission to challenge.” The Patient Safety Initiative is impacting and enhancing the culture of safety at Shapiro’s practice and in surgical patient care at Piedmont Atlanta Hospital.

“Safety is crucial in protecting lives in both aviation and health care, and the need to be consistent and manage the unexpected is a constant,” he adds. Shapiro’s practice is the pilot program for a national rollout to American Anesthesiology’s 1,700 anesthesia providers throughout nine states.


While CRM, checklists and timeouts can help improve unintentional poor listening habits, they don’t do anything to address communication breakdowns that occur due to the hierarchical structure of the OR. This structure creates “a power imbalance that interferes with effective communication because it frequently prevents people from speaking up,” stated The AORN Journal article.

When OR team members collaborate effectively, hierarchical roles will no longer constrict their ability to communicate. However, “this requires a culture change that may be difficult for OR personnel because of the powerful OR hierarchy,” the article concludes.



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