More Than Talking About the Weekend: Content of Case-Irrelevant Communication Within the OR Team

More Than Talking About the Weekend: Content of Case-Irrelevant Communication Within the OR Team Background Case-irrelevant communication (CIC) is defined as ‘‘any conversation’’ irrelevant to the case. It includes small talk, but also communication related to other work issues besides the actual task. CIC during surgeries is generally seen as distracting, despite a lack of knowledge about the content of CIC and its regulation in terms of adjustments to the situation of CIC. Primary goal of the study was to evaluate CIC content; secondary goal was to evaluate whether surgical teams regulate CIC according to different concentration demands of surgical procedures. Methods In 125 surgeries, 1396 CIC events were observed. CIC were content coded into work-related CIC (per- taining to other tasks or work in general) and social CIC (pertaining to acquaintance talk, gossip, or private conversation). The impact of different phases and the difficulty of the surgical procedure on CIC were assessed. Results Work-related CIC were significantly more frequent (2.49 per hour, SD = 2.17) than social CIC (1.42 per hour, SD = 2.17). Across phases, frequency of work-related CIC was constant, whereas social CIC increased significantly across phases. In surgeries assessed as highly difficult by the surgeons, social CIC were observed at a lower frequency, and less work-related CIC were observed during the main phase compared to surgeries assessed as less difficult. Conclusion The high proportion of work-related CIC indicates that surgical teams deal with other tasks during surgeries. Surgical teams adapt CIC according to the demands of the procedure. Hospital policies should support these adaptations rather than attempt to suppress CIC entirely. Introduction during surgeries [1–4]. A potential distractor is case-irrel- evant communication, which is the focus of this study. In Performing surgery is a complex task that requires high particular, this study aims to describe (1) type and fre- concentration. However, interruptions and distractions that quency of case-irrelevant communication and (2) the reg- may threaten this concentration are frequently observed ulation of case-irrelevant communication within the surgical team. Communication within a surgical team during the pro- & Guido Beldi cedure can be related to the actual case (case-relevant guido.beldi@insel.ch communication) or it can be case-irrelevant (CIC). CIC is Department of Visceral Surgery and Medicine, University defined very generally as ‘‘any conversation’’ irrelevant to Hospital of Bern, 3010 Bern, Switzerland the case and may include small talk, but also communi- University of Neuchatel, Institute of Work and cation related to other work issues besides the actual task Organizational Psychology, Neuchatel, Switzerland (e.g., discussions about other patients; scheduling of other Department of Psychology, University of Berne, Bern, procedures) [5, 6]. Switzerland 123 2012 World J Surg (2018) 42:2011–2017 Because CIC is not necessary or useful for the task at that surgical teams regulate CIC specifically in the middle hand, it is often seen as a ‘‘communication problem’’ that or very difficult phases of a surgical procedure. needs to be dealt with in the operating room, and is studied In sum, CIC during surgery may be necessary, helpful or together with other distractors [7]. Compared to other distracting. However, neither the content CIC nor the distractor categories such as door openings or noise events, regulation of CIC within the surgical team has been CIC is more frequently observed during the intraoperative explored in detail. Therefore, the primary goal of the cur- or early postoperative phases [2, 3, 6, 8–14]. Frequencies rent study is to explore the content of CIC during elective of CIC range from about every 20 min in shorter (\4h) surgical procedures, and the secondary goal is to investi- [12] to every 10 min in long open abdominal procedures gate the regulation of CIC within the surgical team across [15]. different phases of surgical procedures of different Because the surgical team is involved in generating CIC, complexity. it potentially binds more attention of the surgical team than other distractors. Thus, CIC could be particularly harmful for concentration [3, 12]. Although surgeons report less Materials and methods concentration if more CICs are observed, recent reports show that the distracting potential of CIC is in the medium Inclusion criteria for observations were open abdominal range and distracts less than issues involving technical procedures with an expected duration of at least 1 h and the equipment or procedural problems [8, 13]. A recent study availability of observers. A total of 193 procedures were suggests that the distracting potential of overall CIC is observed in a European University hospital. In one surgery, highly dependent on the context within the procedure, as no CIC was observed. Sixty-seven surgeries had to be CIC impacts on clinical outcome only when frequent dur- excluded because the observers could not determine CIC ing the closing phase of the surgery [15]. content precisely enough (e.g., because team members Despite its potential to distract, CIC may exhibit talked at a very low voice) for more than 70% of the CIC. important other, even positive, functions. First, CIC related The final sample consists of 125 procedures (Fig. 1), per- to other aspects of work may be required to solve other formed by 20 different main surgeons. problems that typically occur simultaneously to surgeries in clinical practice, such as responding to questions about other patients, or organizational issues [16]. Indeed, 25% of observed CIC have been found to be related to other patients [6]. A second important function of CIC may be social. Small talk can relax the atmosphere within the surgical team and release tension and thereby be important for good teamwork [17–19]. Thus, CIC may contribute to a good social climate and may be a sign of transformational leadership, a form of leadership which is advantageous in the OR [20]. Regulation of CIC within the surgical team is likely to be highly complex. Most of CIC is initiated by surgeons [2, 6, 13], and it is almost always targeted at other surgeons [6]. CIC can in general be controlled by the surgical team, e.g., by avoiding CIC when the concentration demands of the tasks are high [9, 21]. This type of regulation is anal- ogous to talking to a passenger while driving: Although the distracting potential of conversations with passengers has been shown, drivers as well as passengers react to changes in driving conditions by limiting their conversations in heavy traffic [22]. It is thus reasonable to expect surgeons to engage less in CIC in phases of the procedure when high concentration is needed; as has been observed for other distractors [23]. The middle phase of a surgical procedure has been shown to be associated with the highest difficulty, whereas early or late phases (opening and closure) typi- Fig. 1 Flowchart cally are less challenging [12, 13, 24]. One can thus expect 123 World J Surg (2018) 42:2011–2017 2013 The internal institutional review board agreed to the 6. Private conversations include talking about one’s own observation of the surgical teams. Individuals were con- personal life (excluding professional biography). sented with an opt-out procedure, as each member of the Examples include talking about one’s children or pets; team could at any moment ask the observational team to talking about a recent popular vote. leave. If a conversation involved several categories, the most predominant category was coded, so that each CIC repre- Observation and content coding of CIC sents only one category. CICs that could not be categorized were noted. For validation purposes, two coders indepen- Each surgery was observed by trained observers (work and dently categorized 22% of the comments. Interobserver organizational psychologists), using a validated event- agreement (Cohen’s weighted kappa) was 0.76, which based observational system [25]. The observation period indicates good interobserver reliability: the rest of the was between skin incision and end of skin closure. The comments were coded by the first author [27]. observers were seated in about 1.5 m distance from the operating table, opposite to the lead surgeon. The observers Case-related communication coded each verbal exchange within the sterile team and between at least one member of the sterile team and the Case-related communication was coded if the surgical team anesthesiologists. CIC was coded if the surgical team engaged in topics related to the patient or the procedure, engaged in topics that were not related to the patient or the including case-related teaching and leadership [25]. procedure. If the team engaged in a CIC, the observers first noted Difficulty of surgery that the CIC took place; the time was automatically recorded. If the observers could understand the content of After each surgery, just before leaving the operation room, CIC, they summarized it in the comment section of the the surgeons completed a short standardized questionnaire coding application. Each observational comment was then to evaluate the difficulty of the operation. Difficulty was content coded [26] into two main categories (related to assessed with the question ‘‘How difficult was the surgery work vs. small talk) with three distinct sub-categories each, for you?’’ and assessed on a 7-point Likert type scale with according to the following description. scores between 1 (very easy) to 7 (very difficult). If more Main category work-related CIC: than one surgeon was present, their difficulty assessments 1. Other tasks or patients Examples are a conversation were averaged. Difficulty levels were split at the mean about an assistant physician who was asked to help out (4.5) in low and high difficult procedures; thus, 49.6% of the surgeries were categorized as low difficulty. Ques- in a surgery in another OR, or a conversation about the next patient or a patient in the emergency room. tionnaires were confidential. 2. Work and medicine in general Examples are a conversation about reducing the number of instruments Phase of surgery that are required during operations; the surgeons discussing how to avoid back problems while doing Three different phases of the surgery were distinguished surgery. according to the presence of the main and most experi- 3. Context talk related to the surgery included comments enced (senior) surgeon [28, 29]. In 102 of the 125 surg- about the context of the current surgery or its eries, the senior surgeon joined the team after the organizational aspects. Examples are the general preparatory phase, stayed for the main phase, and left the quality of technical devices; the student asking for surgery before the closing phase, this is customary in this institution, where fellows with board examination often are permission to leave and explaining the reasons. responsible for the first and last part of the procedure. The Main category social CIC (small talk): main phase can be considered the most difficult part of the 4. Acquaintance talk included introducing new collabo- surgery [29]. All surgical steps during this period were rators and talking about one’s own biography. Exam- either performed or were closely supervised by the senior ples are that the surgeon asks the student to repeat her surgeon. Thus, phases were defined as follows: name and asks how long she will stay in the service; a phase 1: before the senior surgeon is present surgeon talks about his work biography. phase 2: senior surgeon present 5. Gossip includes exchanging information about other phase 3: senior surgeon left the operation people. Examples are talking about opinions of a colleague not present, talk about hospital policies. 123 2014 World J Surg (2018) 42:2011–2017 Table 1 Operative procedures and descriptive statistics significant. Mann–Whitney U test were used for compar- isons, t-tests for repeated measures and analyses of vari- (n = 125) ances for repeated measures were used to compare CIC Patient age (SD) 61.5 (14.8) across and phases. Post hoc comparisons were Bonferroni Duration of surgery in hours (SD) 4.5 (2.0) corrected. Patient gender (% males) 68 (55.9%) Type of surgery Hepatobiliary/pancreatic 63 (50.4%) Results Upper GI tract 24 (19.2%) Lower GI tract 22 (17.6%) Frequency of CIC Other 16 (12.8%) Average surgeon’s evaluation of difficulty level 4.48 (1.05) In the 125 surgeries included (Table 1), 1396 CICs were (range 1–7, SD) observed; with a mean of 11.17 per surgery (SD = 8.79), a Proportion CIC content coded (SD) 88.9% (10.4) range of 1–48 per surgery, and a density of 2.97 CIC (SD = 3.50) per hour of surgery. Work-related CICs were SD standard deviation observed at a frequency of 2.49 observations per hour with a standard deviation (SD) of 2.17, social CIC were Outcome parameters observed at 1.42 (SD 2.17) per hour (P \ 0.001). During procedures, the frequency of overall work-related CIC did The primary outcome of the study was the frequency of not change significantly; however, the frequency of social content of CIC, according to the main and sub-categories. CIC was significantly higher in the last phase (Table 2 and The secondary outcome was the content of CIC of the two Fig. 2a, b). CIC amounted to 12.89% (SD = 10.13%) of all main categories for easy and difficult surgeries across the observed communication within the sterile team. three phases. Regulation of CIC Statistical analyses We tested whether the surgical teams regulated the fre- For statistical analysis, we used SPSS (IBM Corp. Released quency of CIC according to the difficulty of the procedure 2013. IBM SPSS Statistics for Macintosh, Version 24.0. and the phase. The frequency of work-related CIC was not Armonk, NY: IBM Corp.). Non-parametrical data are dis- different for low and high difficult surgeries overall. played as median and interquartile range (IQR), paramet- However, in phase 2, significantly less work-related CIC rical data as mean and standard deviation (SD). Inter-rater was observed in difficult surgeries (Table 3). The fre- agreement was assessed using Cohen’s weighted Kappa quency of social CIC was significantly lower in difficult statistics. A P value below 0.05 was defined as statistical Table 2 Content categories of CIC overall, and in phase 1, 2 or 3, respectively Overall mean (SD)/ min–max/per Phase 1 mean (SD)/ Phase 2 mean (SD)/ Phase 3 mean (SD)/ P value per hour hour per hour per hour per hour (phases) N = 125 n = 102 Work-related CIC 2.49 (2.17) 0–14.7 2.09 (2.97) 2.40 (2.29) 2.35 (3.09) 0.618 a a a Other 0.70 (0.95) 0–8.3 0.41 (0.80) 0.76 (0.86) 0.58 (1.27) 0.028 a b a,b tasks/patients Work/medicine in 0.44 (0.78) 0–6.0 0.18 (0.83) 0.47 (1.01) 0.41 (0.86) 0.029 a b c general Context of surgery 1.34 (1.11) 0–5.4 1.51 (2.68) 1.18 (1.32) 1.35 (2.37) 0.517 a a a Social CIC (small 1.42 (2.17) 0–20.2 0.89 (1.52) 1.02 (1.25) 1.86 (3.83) 0.005 a a b talk) Acquaintance talk 0.13 (0.23) 0–1.0 0.14 (0.42) 0.07 (0.18) 0.17 (0.60) 0.27 a a a Gossip 0.26 (0.48) 0–2.4 0.15 (0.41) 0.20 (0.43) 0.39 (1.33) 0.1 a a a Private 1.02 (2.01) 0–20.2 0.28 (1.17) 0.75 (0.97) 1.20 (3.45) 0.038 a a,b b conversations Bold values indicate statistical significance (P \ 0.05) Phases with different subscripts were significantly different from each other (across rows, Bonferroni-corrected post hoc tests) 123 World J Surg (2018) 42:2011–2017 2015 1.4 social CIC per hour; only about 13 percent of all Work-related CIC communication was CIC. Work-related CIC occurred more 3.0 Overall work-related CIC frequently, but overall, remained constant across proce- Context of surgery dures, whereas social CIC density significantly increased 2.0 Other tasks/patients throughout a procedure. Within work-related CIC, con- Work/medicine in general versations related to the context of the surgery were most 1.0 prevalent. (1,2) The presence of the senior surgeon critically influenced (1) the frequency of work CIC related to other tasks/patients 0.0 and general topics, as these were more often observed in the main operating phase with the most senior surgeon present. This may be the consequence of different positions within the hierarchical structure: The most senior surgeon Social CIC Overall social CIC may more often address specific organisational questions Private conversations than more junior surgeons. The potential negative, dis- Gossip (2,3) tracting aspect of work-related CIC may be attenuated, Acquaintance talk because during difficult surgeries, the surgical teams (3) engaged in significantly less work-related CIC during the second, the main phase. This indicates that the teams reg- ulated work-related CIC according to varying concentra- tion requirements. The frequency of social CIC in general was highest during the last phase of the surgery, after the senior surgeon Fig. 2 a Frequency of work-related CIC across phases: (1) had left. This increase is mainly due to private conversa- significant difference between phase 1 and phase 2; (2) significant tions. The increase may represent a more relaxed social difference between phase 2 and phase 3. b Frequency of social CIC climate after the most difficult main phase—although it across phases: (2) significant difference between phase 2 and phase cannot be excluded that the effect is simply due to the fact 3; (3) significant difference between phase 1 and phase 3 that the senior surgeon has left. As social CIC implies rather low concentration demands [30], it could also be that surgeries than in less difficult surgeries. However, there fatigue after long operations contributed to the increase of was no statistically significant difference within the three social CIC. In that case, CIC may represent a surrogate phases of the surgery (Table 3). parameter for decreasing concentration of the team. Overall, but not across phases, the surgical team engages in less social CIC in difficult surgeries. This, again, shows Discussion that the surgical teams adapted to the higher concentration demands in difficult surgeries. The study showed that CIC could be clearly distinguished Overall, the results show that if surgical teams do not in work-related CIC and social CIC. Overall, CIC did not communicate about the patient or the surgery at hand, they occur very frequently, with about 2.5 work-related CIC and more often engage in work-related CIC than in social CIC. Table 3 Work-related and social CIC across phases for surgeries with high and low difficulty ratings Difficulty level Phase 1 Phase 2 Phase 3 Overall Before senior surgeon arrives Senior surgeon present After senior surgeon leaves Median (IQR) Median (IQR) Median (IQR) Median (IQR) Work-related CIC Low 1.42 (3.05) 2.22 (2.45) 1.42 (5.40) 2.37 (2.20) High 1.23 (3.08) 1.39 (1.80) 1.39 (3.03) 1.93 (1.54) P 0.634 0.023 0.854 0.080 Social CIC Low 0 (1.51) 0.8 (1.93) 0.87 (2.69) 1.18 (1.76) High 0 (0.99) 0.61 (1.12) 0.68 (1.77) 0.73 (1.19) P 0.42 0.24 0.414 0.023 Bold values indicate statistical significance (P \ 0.05) IQR interquartile range P-values are based on M–W nonparametric tests phase 1 phase 2 phase 3 phase 1 phase 2 phase 3 work-related CIC per hour Social CIC per hour 2016 World J Surg (2018) 42:2011–2017 2. Healey AN, Primus CP, Koutantji M (2007) Quantifying dis- This indicates that they are dealing with other work-related traction and interruption in urological surgery. Qual Saf Health aspects during surgeries. Although work-related CIC may Care 16:135–139 be a distractor for the surgery at hand, it may be functional 3. Healey AN, Sevdalis N, Vincent C (2006) Measuring intra-op- for the other tasks surgeons have to do outside of the OR. erative interference from distraction and interruption observed in the operating theatre. Ergonomics 49:589–604 Social CIC may be good for social aspects, but ques- 4. Mentis HM, Chellali A, Manser K et al (2016) A systematic tionable with regard to patient outcomes, as a previous review of the effect of distraction on surgeon performance: study showed [15]. Again, surgical teams regulate social directions for operating room policy and surgical training. Surg CIC if concentration demands are high. Given these and Endosc 30:1713–1724 5. Healey AN, Olsen SE, Davis R et al (2008) A method for mea- previous findings, we propose that social CIC need to be suring work interference in surgical teams. Cogn Technol Work assessed specifically in future studies in order to identify 10:305–312 any potential impact on concentration and quality, but also 6. Sevdalis N, Healey AN, Vincent CA (2007) Distracting com- on patient outcomes. munications in the operating theatre. J Eval Clin Pract 13:390–394 The results of this study do not support a recommen- 7. Weldon SM, Korkiakangas T, Bezemer J et al (2013) Commu- dation for changes in general policies in the operating room nication in the operating theatre. Br J Surg 100:1677–1688 with regard to CIC [8, 31]. Both work and social CIC seem 8. Mentis HM, Chellali A, Manser K et al (2016) A systematic to be at least partially functional and should neither be review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training. Surg avoided nor completely suppressed. Work CIC may be Endosc 30(5):1713–1724 necessary for the coordination of work beyond the actual 9. 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More Than Talking About the Weekend: Content of Case-Irrelevant Communication Within the OR Team

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Medicine & Public Health; Surgery; Abdominal Surgery; Cardiac Surgery; General Surgery; Thoracic Surgery; Vascular Surgery
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Abstract

Background Case-irrelevant communication (CIC) is defined as ‘‘any conversation’’ irrelevant to the case. It includes small talk, but also communication related to other work issues besides the actual task. CIC during surgeries is generally seen as distracting, despite a lack of knowledge about the content of CIC and its regulation in terms of adjustments to the situation of CIC. Primary goal of the study was to evaluate CIC content; secondary goal was to evaluate whether surgical teams regulate CIC according to different concentration demands of surgical procedures. Methods In 125 surgeries, 1396 CIC events were observed. CIC were content coded into work-related CIC (per- taining to other tasks or work in general) and social CIC (pertaining to acquaintance talk, gossip, or private conversation). The impact of different phases and the difficulty of the surgical procedure on CIC were assessed. Results Work-related CIC were significantly more frequent (2.49 per hour, SD = 2.17) than social CIC (1.42 per hour, SD = 2.17). Across phases, frequency of work-related CIC was constant, whereas social CIC increased significantly across phases. In surgeries assessed as highly difficult by the surgeons, social CIC were observed at a lower frequency, and less work-related CIC were observed during the main phase compared to surgeries assessed as less difficult. Conclusion The high proportion of work-related CIC indicates that surgical teams deal with other tasks during surgeries. Surgical teams adapt CIC according to the demands of the procedure. Hospital policies should support these adaptations rather than attempt to suppress CIC entirely. Introduction during surgeries [1–4]. A potential distractor is case-irrel- evant communication, which is the focus of this study. In Performing surgery is a complex task that requires high particular, this study aims to describe (1) type and fre- concentration. However, interruptions and distractions that quency of case-irrelevant communication and (2) the reg- may threaten this concentration are frequently observed ulation of case-irrelevant communication within the surgical team. Communication within a surgical team during the pro- & Guido Beldi cedure can be related to the actual case (case-relevant guido.beldi@insel.ch communication) or it can be case-irrelevant (CIC). CIC is Department of Visceral Surgery and Medicine, University defined very generally as ‘‘any conversation’’ irrelevant to Hospital of Bern, 3010 Bern, Switzerland the case and may include small talk, but also communi- University of Neuchatel, Institute of Work and cation related to other work issues besides the actual task Organizational Psychology, Neuchatel, Switzerland (e.g., discussions about other patients; scheduling of other Department of Psychology, University of Berne, Bern, procedures) [5, 6]. Switzerland 123 2012 World J Surg (2018) 42:2011–2017 Because CIC is not necessary or useful for the task at that surgical teams regulate CIC specifically in the middle hand, it is often seen as a ‘‘communication problem’’ that or very difficult phases of a surgical procedure. needs to be dealt with in the operating room, and is studied In sum, CIC during surgery may be necessary, helpful or together with other distractors [7]. Compared to other distracting. However, neither the content CIC nor the distractor categories such as door openings or noise events, regulation of CIC within the surgical team has been CIC is more frequently observed during the intraoperative explored in detail. Therefore, the primary goal of the cur- or early postoperative phases [2, 3, 6, 8–14]. Frequencies rent study is to explore the content of CIC during elective of CIC range from about every 20 min in shorter (\4h) surgical procedures, and the secondary goal is to investi- [12] to every 10 min in long open abdominal procedures gate the regulation of CIC within the surgical team across [15]. different phases of surgical procedures of different Because the surgical team is involved in generating CIC, complexity. it potentially binds more attention of the surgical team than other distractors. Thus, CIC could be particularly harmful for concentration [3, 12]. Although surgeons report less Materials and methods concentration if more CICs are observed, recent reports show that the distracting potential of CIC is in the medium Inclusion criteria for observations were open abdominal range and distracts less than issues involving technical procedures with an expected duration of at least 1 h and the equipment or procedural problems [8, 13]. A recent study availability of observers. A total of 193 procedures were suggests that the distracting potential of overall CIC is observed in a European University hospital. In one surgery, highly dependent on the context within the procedure, as no CIC was observed. Sixty-seven surgeries had to be CIC impacts on clinical outcome only when frequent dur- excluded because the observers could not determine CIC ing the closing phase of the surgery [15]. content precisely enough (e.g., because team members Despite its potential to distract, CIC may exhibit talked at a very low voice) for more than 70% of the CIC. important other, even positive, functions. First, CIC related The final sample consists of 125 procedures (Fig. 1), per- to other aspects of work may be required to solve other formed by 20 different main surgeons. problems that typically occur simultaneously to surgeries in clinical practice, such as responding to questions about other patients, or organizational issues [16]. Indeed, 25% of observed CIC have been found to be related to other patients [6]. A second important function of CIC may be social. Small talk can relax the atmosphere within the surgical team and release tension and thereby be important for good teamwork [17–19]. Thus, CIC may contribute to a good social climate and may be a sign of transformational leadership, a form of leadership which is advantageous in the OR [20]. Regulation of CIC within the surgical team is likely to be highly complex. Most of CIC is initiated by surgeons [2, 6, 13], and it is almost always targeted at other surgeons [6]. CIC can in general be controlled by the surgical team, e.g., by avoiding CIC when the concentration demands of the tasks are high [9, 21]. This type of regulation is anal- ogous to talking to a passenger while driving: Although the distracting potential of conversations with passengers has been shown, drivers as well as passengers react to changes in driving conditions by limiting their conversations in heavy traffic [22]. It is thus reasonable to expect surgeons to engage less in CIC in phases of the procedure when high concentration is needed; as has been observed for other distractors [23]. The middle phase of a surgical procedure has been shown to be associated with the highest difficulty, whereas early or late phases (opening and closure) typi- Fig. 1 Flowchart cally are less challenging [12, 13, 24]. One can thus expect 123 World J Surg (2018) 42:2011–2017 2013 The internal institutional review board agreed to the 6. Private conversations include talking about one’s own observation of the surgical teams. Individuals were con- personal life (excluding professional biography). sented with an opt-out procedure, as each member of the Examples include talking about one’s children or pets; team could at any moment ask the observational team to talking about a recent popular vote. leave. If a conversation involved several categories, the most predominant category was coded, so that each CIC repre- Observation and content coding of CIC sents only one category. CICs that could not be categorized were noted. For validation purposes, two coders indepen- Each surgery was observed by trained observers (work and dently categorized 22% of the comments. Interobserver organizational psychologists), using a validated event- agreement (Cohen’s weighted kappa) was 0.76, which based observational system [25]. The observation period indicates good interobserver reliability: the rest of the was between skin incision and end of skin closure. The comments were coded by the first author [27]. observers were seated in about 1.5 m distance from the operating table, opposite to the lead surgeon. The observers Case-related communication coded each verbal exchange within the sterile team and between at least one member of the sterile team and the Case-related communication was coded if the surgical team anesthesiologists. CIC was coded if the surgical team engaged in topics related to the patient or the procedure, engaged in topics that were not related to the patient or the including case-related teaching and leadership [25]. procedure. If the team engaged in a CIC, the observers first noted Difficulty of surgery that the CIC took place; the time was automatically recorded. If the observers could understand the content of After each surgery, just before leaving the operation room, CIC, they summarized it in the comment section of the the surgeons completed a short standardized questionnaire coding application. Each observational comment was then to evaluate the difficulty of the operation. Difficulty was content coded [26] into two main categories (related to assessed with the question ‘‘How difficult was the surgery work vs. small talk) with three distinct sub-categories each, for you?’’ and assessed on a 7-point Likert type scale with according to the following description. scores between 1 (very easy) to 7 (very difficult). If more Main category work-related CIC: than one surgeon was present, their difficulty assessments 1. Other tasks or patients Examples are a conversation were averaged. Difficulty levels were split at the mean about an assistant physician who was asked to help out (4.5) in low and high difficult procedures; thus, 49.6% of the surgeries were categorized as low difficulty. Ques- in a surgery in another OR, or a conversation about the next patient or a patient in the emergency room. tionnaires were confidential. 2. Work and medicine in general Examples are a conversation about reducing the number of instruments Phase of surgery that are required during operations; the surgeons discussing how to avoid back problems while doing Three different phases of the surgery were distinguished surgery. according to the presence of the main and most experi- 3. Context talk related to the surgery included comments enced (senior) surgeon [28, 29]. In 102 of the 125 surg- about the context of the current surgery or its eries, the senior surgeon joined the team after the organizational aspects. Examples are the general preparatory phase, stayed for the main phase, and left the quality of technical devices; the student asking for surgery before the closing phase, this is customary in this institution, where fellows with board examination often are permission to leave and explaining the reasons. responsible for the first and last part of the procedure. The Main category social CIC (small talk): main phase can be considered the most difficult part of the 4. Acquaintance talk included introducing new collabo- surgery [29]. All surgical steps during this period were rators and talking about one’s own biography. Exam- either performed or were closely supervised by the senior ples are that the surgeon asks the student to repeat her surgeon. Thus, phases were defined as follows: name and asks how long she will stay in the service; a phase 1: before the senior surgeon is present surgeon talks about his work biography. phase 2: senior surgeon present 5. Gossip includes exchanging information about other phase 3: senior surgeon left the operation people. Examples are talking about opinions of a colleague not present, talk about hospital policies. 123 2014 World J Surg (2018) 42:2011–2017 Table 1 Operative procedures and descriptive statistics significant. Mann–Whitney U test were used for compar- isons, t-tests for repeated measures and analyses of vari- (n = 125) ances for repeated measures were used to compare CIC Patient age (SD) 61.5 (14.8) across and phases. Post hoc comparisons were Bonferroni Duration of surgery in hours (SD) 4.5 (2.0) corrected. Patient gender (% males) 68 (55.9%) Type of surgery Hepatobiliary/pancreatic 63 (50.4%) Results Upper GI tract 24 (19.2%) Lower GI tract 22 (17.6%) Frequency of CIC Other 16 (12.8%) Average surgeon’s evaluation of difficulty level 4.48 (1.05) In the 125 surgeries included (Table 1), 1396 CICs were (range 1–7, SD) observed; with a mean of 11.17 per surgery (SD = 8.79), a Proportion CIC content coded (SD) 88.9% (10.4) range of 1–48 per surgery, and a density of 2.97 CIC (SD = 3.50) per hour of surgery. Work-related CICs were SD standard deviation observed at a frequency of 2.49 observations per hour with a standard deviation (SD) of 2.17, social CIC were Outcome parameters observed at 1.42 (SD 2.17) per hour (P \ 0.001). During procedures, the frequency of overall work-related CIC did The primary outcome of the study was the frequency of not change significantly; however, the frequency of social content of CIC, according to the main and sub-categories. CIC was significantly higher in the last phase (Table 2 and The secondary outcome was the content of CIC of the two Fig. 2a, b). CIC amounted to 12.89% (SD = 10.13%) of all main categories for easy and difficult surgeries across the observed communication within the sterile team. three phases. Regulation of CIC Statistical analyses We tested whether the surgical teams regulated the fre- For statistical analysis, we used SPSS (IBM Corp. Released quency of CIC according to the difficulty of the procedure 2013. IBM SPSS Statistics for Macintosh, Version 24.0. and the phase. The frequency of work-related CIC was not Armonk, NY: IBM Corp.). Non-parametrical data are dis- different for low and high difficult surgeries overall. played as median and interquartile range (IQR), paramet- However, in phase 2, significantly less work-related CIC rical data as mean and standard deviation (SD). Inter-rater was observed in difficult surgeries (Table 3). The fre- agreement was assessed using Cohen’s weighted Kappa quency of social CIC was significantly lower in difficult statistics. A P value below 0.05 was defined as statistical Table 2 Content categories of CIC overall, and in phase 1, 2 or 3, respectively Overall mean (SD)/ min–max/per Phase 1 mean (SD)/ Phase 2 mean (SD)/ Phase 3 mean (SD)/ P value per hour hour per hour per hour per hour (phases) N = 125 n = 102 Work-related CIC 2.49 (2.17) 0–14.7 2.09 (2.97) 2.40 (2.29) 2.35 (3.09) 0.618 a a a Other 0.70 (0.95) 0–8.3 0.41 (0.80) 0.76 (0.86) 0.58 (1.27) 0.028 a b a,b tasks/patients Work/medicine in 0.44 (0.78) 0–6.0 0.18 (0.83) 0.47 (1.01) 0.41 (0.86) 0.029 a b c general Context of surgery 1.34 (1.11) 0–5.4 1.51 (2.68) 1.18 (1.32) 1.35 (2.37) 0.517 a a a Social CIC (small 1.42 (2.17) 0–20.2 0.89 (1.52) 1.02 (1.25) 1.86 (3.83) 0.005 a a b talk) Acquaintance talk 0.13 (0.23) 0–1.0 0.14 (0.42) 0.07 (0.18) 0.17 (0.60) 0.27 a a a Gossip 0.26 (0.48) 0–2.4 0.15 (0.41) 0.20 (0.43) 0.39 (1.33) 0.1 a a a Private 1.02 (2.01) 0–20.2 0.28 (1.17) 0.75 (0.97) 1.20 (3.45) 0.038 a a,b b conversations Bold values indicate statistical significance (P \ 0.05) Phases with different subscripts were significantly different from each other (across rows, Bonferroni-corrected post hoc tests) 123 World J Surg (2018) 42:2011–2017 2015 1.4 social CIC per hour; only about 13 percent of all Work-related CIC communication was CIC. Work-related CIC occurred more 3.0 Overall work-related CIC frequently, but overall, remained constant across proce- Context of surgery dures, whereas social CIC density significantly increased 2.0 Other tasks/patients throughout a procedure. Within work-related CIC, con- Work/medicine in general versations related to the context of the surgery were most 1.0 prevalent. (1,2) The presence of the senior surgeon critically influenced (1) the frequency of work CIC related to other tasks/patients 0.0 and general topics, as these were more often observed in the main operating phase with the most senior surgeon present. This may be the consequence of different positions within the hierarchical structure: The most senior surgeon Social CIC Overall social CIC may more often address specific organisational questions Private conversations than more junior surgeons. The potential negative, dis- Gossip (2,3) tracting aspect of work-related CIC may be attenuated, Acquaintance talk because during difficult surgeries, the surgical teams (3) engaged in significantly less work-related CIC during the second, the main phase. This indicates that the teams reg- ulated work-related CIC according to varying concentra- tion requirements. The frequency of social CIC in general was highest during the last phase of the surgery, after the senior surgeon Fig. 2 a Frequency of work-related CIC across phases: (1) had left. This increase is mainly due to private conversa- significant difference between phase 1 and phase 2; (2) significant tions. The increase may represent a more relaxed social difference between phase 2 and phase 3. b Frequency of social CIC climate after the most difficult main phase—although it across phases: (2) significant difference between phase 2 and phase cannot be excluded that the effect is simply due to the fact 3; (3) significant difference between phase 1 and phase 3 that the senior surgeon has left. As social CIC implies rather low concentration demands [30], it could also be that surgeries than in less difficult surgeries. However, there fatigue after long operations contributed to the increase of was no statistically significant difference within the three social CIC. In that case, CIC may represent a surrogate phases of the surgery (Table 3). parameter for decreasing concentration of the team. Overall, but not across phases, the surgical team engages in less social CIC in difficult surgeries. This, again, shows Discussion that the surgical teams adapted to the higher concentration demands in difficult surgeries. The study showed that CIC could be clearly distinguished Overall, the results show that if surgical teams do not in work-related CIC and social CIC. Overall, CIC did not communicate about the patient or the surgery at hand, they occur very frequently, with about 2.5 work-related CIC and more often engage in work-related CIC than in social CIC. Table 3 Work-related and social CIC across phases for surgeries with high and low difficulty ratings Difficulty level Phase 1 Phase 2 Phase 3 Overall Before senior surgeon arrives Senior surgeon present After senior surgeon leaves Median (IQR) Median (IQR) Median (IQR) Median (IQR) Work-related CIC Low 1.42 (3.05) 2.22 (2.45) 1.42 (5.40) 2.37 (2.20) High 1.23 (3.08) 1.39 (1.80) 1.39 (3.03) 1.93 (1.54) P 0.634 0.023 0.854 0.080 Social CIC Low 0 (1.51) 0.8 (1.93) 0.87 (2.69) 1.18 (1.76) High 0 (0.99) 0.61 (1.12) 0.68 (1.77) 0.73 (1.19) P 0.42 0.24 0.414 0.023 Bold values indicate statistical significance (P \ 0.05) IQR interquartile range P-values are based on M–W nonparametric tests phase 1 phase 2 phase 3 phase 1 phase 2 phase 3 work-related CIC per hour Social CIC per hour 2016 World J Surg (2018) 42:2011–2017 2. Healey AN, Primus CP, Koutantji M (2007) Quantifying dis- This indicates that they are dealing with other work-related traction and interruption in urological surgery. Qual Saf Health aspects during surgeries. Although work-related CIC may Care 16:135–139 be a distractor for the surgery at hand, it may be functional 3. Healey AN, Sevdalis N, Vincent C (2006) Measuring intra-op- for the other tasks surgeons have to do outside of the OR. erative interference from distraction and interruption observed in the operating theatre. Ergonomics 49:589–604 Social CIC may be good for social aspects, but ques- 4. Mentis HM, Chellali A, Manser K et al (2016) A systematic tionable with regard to patient outcomes, as a previous review of the effect of distraction on surgeon performance: study showed [15]. Again, surgical teams regulate social directions for operating room policy and surgical training. Surg CIC if concentration demands are high. Given these and Endosc 30:1713–1724 5. Healey AN, Olsen SE, Davis R et al (2008) A method for mea- previous findings, we propose that social CIC need to be suring work interference in surgical teams. Cogn Technol Work assessed specifically in future studies in order to identify 10:305–312 any potential impact on concentration and quality, but also 6. Sevdalis N, Healey AN, Vincent CA (2007) Distracting com- on patient outcomes. munications in the operating theatre. J Eval Clin Pract 13:390–394 The results of this study do not support a recommen- 7. Weldon SM, Korkiakangas T, Bezemer J et al (2013) Commu- dation for changes in general policies in the operating room nication in the operating theatre. Br J Surg 100:1677–1688 with regard to CIC [8, 31]. Both work and social CIC seem 8. Mentis HM, Chellali A, Manser K et al (2016) A systematic to be at least partially functional and should neither be review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training. Surg avoided nor completely suppressed. Work CIC may be Endosc 30(5):1713–1724 necessary for the coordination of work beyond the actual 9. Wheelock A, Suliman A, Wharton R et al (2015) The impact of surgery and social CIC are may be good for group climate operating room distractions on stress, workload, and teamwork. [12]. However, CIC should be regulated in accordance with Ann Surg 261:1079–1084 10. Persoon MC, Broos HJ, Witjes JA et al (2011) The effect of the concentration demands of the situation. distractions in the operating room during endourological proce- As a conclusion, CIC is more diverse than simple small dures. Surg Endosc 25:437–443 talk and should be distinguished in work-related and social 11. Sevdalis N, Undre S, McDermott J et al (2014) Impact of intra- CIC. Variations of CIC throughout the phases of surgery operative distractions on patient safety: a prospective descriptive study using validated instruments. World J Surg 38:751–758. and according to the difficulty of the surgery indicate that https://doi.org/10.1007/s00268-013-2315-z the surgical teams adapt their CIC activity to the task at 12. Weigl M, Antoniadis S, Chiapponi C et al (2015) The impact of hand. Policies should support these natural adaptations intra-operative interruptions on surgeons’ perceived workload: an rather than attempt to suppress CIC. observational study in elective general and orthopedic surgery. Surg Endosc 29:145–153 13. Antoniadis S, Passauer-Baierl S, Baschnegger H et al (2014) Acknowledgements We thank Christina Gfeller, Simon Huber, Identification and interference of intraoperative distractions and Nadja Jenni, Franziska Leupi, Moana Monnier, and Julia Seelandt for interruptions in operating rooms. J Surg Res 188:21–29 their help in data collection; Mina Dimitrova for help in coding; Uwe 14. Nagpal K, Abboudi M, Fischler L et al (2011) Evaluation of Klopsch for technical assistance; Brigitte Dubach (head nurse) for her postoperative handover using a tool to assess information transfer support. This study was supported by Swiss National Science Foun- and teamwork. Ann Surg 253:831–837 dation (Grant # CR13I1_138273 and CR13I3_156882, Swiss National 15. Tschan F, Seelandt J, Keller S et al (2015) Impact of case-rele- Competence Center of Affective Sciences). vant and case-irrelevant communication within the surgical team on surgical site infection. Br J Surg 102:1718–1725 Compliance with ethical standards 16. Jothiraj H, Howland-Harris J, Evley R et al (2013) Distractions and the anaesthetist: a qualitative study of context and direction Conflict of interest None of the authors declares a conflict of of distraction. Br J Anaesth 111:477–482 interest. 17. Nembhard IM, Edmondson AC (2006) Making it safe: the effects of leader inclusiveness and professional status on psychological Open Access This article is distributed under the terms of the safety and improvement efforts in health care teams. 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World Journal of SurgerySpringer Journals

Published: Jan 9, 2018

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