Periodic Reporting for period 1 - ROSE (Developing and Applying a Taxonomy of Communication Behaviours and Contextual Factors in Robotic Surgery)
Reporting period: 2023-07-03 to 2025-10-02
Robotic-assisted surgery (RAS) is a minimally invasive surgery in which surgeons use a robotic system to perform precise and complex procedures through a few small incisions. Despite its technical benefits (e.g. improved vision and ergonomics) and improved patient outcomes (e.g. reduced blood loss), RAS changes the spatial configuration in the operating theatre such that the surgeon sits remotely at a console away from the patient and team and has reduced situational awareness on the operative field. The team’s direct view of each other can also be blocked by the robotic equipment. They must use explicit, verbal communication to overcome such limited situational awareness and nonverbal cues. Therefore, the main objectives of the project were (1) to identify effective and ineffective communication behaviours in RAS and (2) to develop and apply an observational framework of these behaviours in robotic surgical teams. The project concluded that there were general as well as specific communication behaviours needed for this particular technology-driven context and that they could be observed and trained. As RAS is increasingly integrated into surgical training and practice, results from the project could be used to train the future generation of surgeons effective communication specifically in the RAS context and prevent communication failures for patient safety.
A scoping review of the existing literature on communication in RAS was conducted. A total of 8,808 results were initially identified, and after removing duplicates, 5,027 articles were eligible for screening. After abstract and title and full-text screening using the inclusion and exclusion criteria, 54 articles were included in the review. Based on the literature review, communication behaviours and contextual factors from existing observational systems of non-technical skills (leadership, communication, teamwork, decision making, and situational awareness) were extracted to develop an initial taxonomy.
To tailor the initial taxonomy towards the RAS context, a total of 35 semi-structured interviews were conducted with operating theatre professionals who were actively performing or assisting RAS. Participants included surgeons (consultants, fellows, and specialist registrars), nurses, and anaesthetist representing urological, general, thoracic, and gynaecological surgery. The sample also represented a diverse background (18 women and 17 men; 23 identified as White, 8 Asian, 3 African American, 1 Middle Eastern). In the interviews, participants were asked to identify effective and ineffective communication in RAS and provide critical incidents of such behaviours. The data were analysed using open coding and inductively to establish content validity of the taxonomy.
The initial taxonomy was used to observe live RAS procedures in the operating theatre. A total of 27 cases in urology were observed. These cases were common urological RAS procedures and took 2 to 4 hours in operative duration. The taxonomy was updated accordingly such that behaviours not identified in the interviews were added to the taxonomy, and behaviours not observed were removed from the taxonomy.
As outcomes of the project, communication behaviours identified could be used as training objectives as well as explicit agreements among surgical team members in clinical practice (i.e. what to do and not to do). Moreover, the taxonomy can also be used to observe and assess communication in RAS. Results from the project were presented at 6 professional meetings including the Behavioural Science Applied to Healthcare, European Chapter of Human Factors and Ergonomics Society, Interdisciplinary Network for Group Research, International Association for Health Professions Education, European Researchers’ Night, and National Human Factors in Patient Safety Conference in Ireland. Furthermore, results will also be published in peer-reviewed journals, such as Journal of Robotic Surgery, Human Factors, British Journal of Surgery, Journal of Surgical Research, Global Surgical Education, and Translational Behavioral Medicine: Practice, Policy, and Research.
To tailor the initial taxonomy towards the RAS context, a total of 35 semi-structured interviews were conducted with operating theatre professionals who were actively performing or assisting RAS. Participants included surgeons (consultants, fellows, and specialist registrars), nurses, and anaesthetist representing urological, general, thoracic, and gynaecological surgery. The sample also represented a diverse background (18 women and 17 men; 23 identified as White, 8 Asian, 3 African American, 1 Middle Eastern). In the interviews, participants were asked to identify effective and ineffective communication in RAS and provide critical incidents of such behaviours. The data were analysed using open coding and inductively to establish content validity of the taxonomy.
The initial taxonomy was used to observe live RAS procedures in the operating theatre. A total of 27 cases in urology were observed. These cases were common urological RAS procedures and took 2 to 4 hours in operative duration. The taxonomy was updated accordingly such that behaviours not identified in the interviews were added to the taxonomy, and behaviours not observed were removed from the taxonomy.
As outcomes of the project, communication behaviours identified could be used as training objectives as well as explicit agreements among surgical team members in clinical practice (i.e. what to do and not to do). Moreover, the taxonomy can also be used to observe and assess communication in RAS. Results from the project were presented at 6 professional meetings including the Behavioural Science Applied to Healthcare, European Chapter of Human Factors and Ergonomics Society, Interdisciplinary Network for Group Research, International Association for Health Professions Education, European Researchers’ Night, and National Human Factors in Patient Safety Conference in Ireland. Furthermore, results will also be published in peer-reviewed journals, such as Journal of Robotic Surgery, Human Factors, British Journal of Surgery, Journal of Surgical Research, Global Surgical Education, and Translational Behavioral Medicine: Practice, Policy, and Research.
Results showed that general effective communication (i.e. communication considered effective not only in RAS but also in other medical situations) included closed-loop communication where the sender initiated a message; the receiver acknowledged receiving the message or clarified the message; and the sender closed the loop by confirming that the message was received or clarifying the message. Effective communication specific to the RAS context included real-time verbal narration where the bedside assistant provided a live commentary of events and activities at the bedside to keep the surgeon informed. Ineffective communication included the lack of speaking up or late speaking up (e.g. relaying critical information about the patient without prompting) due to the visual and psychological barriers created by the spatial configuration inherent in RAS. Open-console RAS systems were more likely to improve communication and situational awareness than closed-console systems. Future research is needed to further understand how surgical team members adapt to using multiple RAS systems which require different communication and coordination strategies due to differences in designs and technical features.
Regarding gender differences in communication, female trainee surgeons were less likely to speak up and ask for training opportunities (e.g. console time as primary operating surgeon) than male counterparts. Moreover, male trainers were likely to be harsher in giving feedback to male trainees than to female trainees. Limited training opportunities in RAS could exacerbate these gender differences and increase barriers for female trainees in gaining independence in their surgical training.
Regarding impacts, results could be incorporated into clinical practice as well as training focusing on communication in RAS so that surgical team members can effectively communicate during surgeries. Effective communication reduces the likelihood of surgical errors and patient complications and improves patient outcomes and quality of life. In addition, institutions could also create a standardised RAS training program (e.g. number of console hours trainees must complete) to reduce potential gender barriers in surgical training and support both male and female trainees reaching their highest potential.
Regarding gender differences in communication, female trainee surgeons were less likely to speak up and ask for training opportunities (e.g. console time as primary operating surgeon) than male counterparts. Moreover, male trainers were likely to be harsher in giving feedback to male trainees than to female trainees. Limited training opportunities in RAS could exacerbate these gender differences and increase barriers for female trainees in gaining independence in their surgical training.
Regarding impacts, results could be incorporated into clinical practice as well as training focusing on communication in RAS so that surgical team members can effectively communicate during surgeries. Effective communication reduces the likelihood of surgical errors and patient complications and improves patient outcomes and quality of life. In addition, institutions could also create a standardised RAS training program (e.g. number of console hours trainees must complete) to reduce potential gender barriers in surgical training and support both male and female trainees reaching their highest potential.