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Sender Sender Transmitted Receiver Receiver Thinks of what to say Communicates message Face to face/phone/email Hears and confirms message Considers and acts

      When communicating face to face a lot of the information is transmitted non‐verbally, which can make telephone or email conversations more challenging. Communication can be more difficult when talking across professional, specialty or hierarchal barriers as we do not always talk the same technical language, have the same levels of understanding, or even have a full awareness of the other person’s role.

      There are a variety of tools to aid communication, for example SBAR (situation, background, assessment and recommendation). SBAR is designed for acute clinical communications. It facilitates the sender to plan and organise the message, make it succinct and focused, and provide it in a logical and expected order. It is also an empowerment tool allowing the sender (who may be more junior) to request an action from a more senior individual. Find out what communication tool your organisation uses and practise using it; look out for other staff using it too. While these tools are useful, they tend to be reserved for certain situations, whereas we want to establish effective communication as the routine not the exception. One method to routinely improve communication is to incorporate a feedback loop.

      Effective communication with a feedback loop

Errors can occur at any level or multiple levels. Consider a busy clinical situation and the team leader shouts ‘We need four units of blood’ or ‘Will someone order four units of blood’ while managing an ongoing postpartum haemorrhage (PPH) – what happens? The majority of times nothing – nobody goes to bring the blood! So how can this be improved? Avoid using instructions like the two examples above – remember – nobody is called ‘someone’! Most obviously an individual can be identified to perform the task, by name: ‘Michael can you please order four units of blood?’ If Michael says ‘Yes’ effective communication might be assumed; but not always. What has Michael heard and what will he do? At the moment we do not really know what message has been received. Michael might dash over with a cup of tea as this is what he thought he heard. This may seem a slightly strange thing to happen; but how often in a clinical emergency have you asked for something and been presented with something else? People are less likely to ask questions in emergencies as everyone is busy. This could be the catalyst for an error or precipitate a missed task. So how do we find out what message Michael received? The easiest way is to use specific ‘task allocation’ incorporated within a formal ‘feedback loop’ (also known as ‘closed loop communication’).

      Now the conversation goes:

      Team leader (Liz):

      ‘Michael, can you please order four units of blood?’

      Michael:

      ‘Okay, you’d like me to order four units of blood?’

      Team leader:

      ‘Correct’

      The loop is finally closed when Michael returns to the room and confirms that the specific allocated task has been done:

      Michael:

      ‘Liz, the four units of blood are ordered and will be here in 5 minutes’

      Team leader:

      ‘Noted Michael – thanks’

      We now know that the message has been transmitted and received correctly. For this process to work both parties (the sender and receiver) need to understand and expect it – again demonstrating the need for us to practise and train together. The phrase ‘Will someone …’ is often used to avoid the embarrassment felt when you cannot remember someone’s name. In emergency situations this must be avoided – use alternative ways of attracting attention: you may need to point or wave at the team member! This is never easy, but is absolutely vital if tasks are to be allocated and completed effectively.

4.7 Team working, leadership and followership

      At a basic level a team is a group of individuals with a common cause. Historically we have tended to train individually or in professional silos; the risk here is that we are making a ‘team of experts’ rather than an ‘expert team’. Often within healthcare our teams form at short notice and may arrive at different times. Much emphasis has previously been given to the role of the leader, but a leader cannot be a team on his or her own. Emphasis needs to be given to developing the other team members, the active followers. A good leader will be able to swap from the role of leader to follower as more senior staff arrive and agree to take over.

      The leader

      The leader’s role is multifaceted and includes directing the team; assigning tasks and assessing performance; motivating and encouraging the team to work together; and planning and organising. All leadership skills and behaviours need to be developed and practised. There are different leadership styles and the leader needs to choose an appropriate style for that situation. Effective communication is key and should be reviewed and reflected upon regularly. Constructive feedback can both be given and sought in order to facilitate continuously improving performance.

       Who is the leader?

      It is vitally important to have a clearly identified leader. There can be times when people come and go, or different specialties arrive, creating a situation where it may not be clear who the leader is. In some situations or institutions individuals will wear tabards or other forms of identification to mitigate against this uncertainty. If there is a scribe recording events they should record who is leading and any changes to the leader.

       Physical position of the leader

      As soon as the leader becomes hands on, and task focused, they are primarily concentrating on the task at hand. This becomes the focus of their thoughts and they lose situation (or situational) awareness (i.e. their objective overview of the situation – see Section 4.8). The term ‘situational leadership’ is used to describe the fact that leadership can change as an emergency develops. If the leader is required to undertake a specific technical task, he/she must hand over leadership at that point. An example would be a situation where the consultant has assumed situational leadership during a shoulder dystocia. The midwife is unable to rotate the shoulders internally and asks the consultant to take over. As the consultant moves in to examine with the aim of removing the posterior arm, he/she must delegate ‘situational leadership’ to someone else – this will often be the senior midwife in the room.

The leader should be standing in an optimal position where they can gather all the information and ideally view the patient, the team members and the monitoring and diagnostic equipment. This enables them to recognise when a member is struggling with a task or procedure and support them appropriately.

      Clear roles

      Ideally the team should meet before the event and have the opportunity to introduce each other, and clarify roles and actions in emergencies. Sometimes this can be facilitated at the beginning of a shift but at other times it is impossible to predict or arrange. It is important, therefore, that individuals identify themselves to the leader as they arrive and roles are agreed, allocated and understood. A lot of the time their role may be determined purely in relation to the specific bleep the individual carries, but it is important that team members are flexible, for example if three airway providers

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