The Uncertainty Room: Strategies for Managing Uncertainty in a Surgical Waiting Room

The Uncertainty Room: Strategies for Managing Uncertainty  in a Surgical Waiting Room

Anne M Stone, PhD; John C Lammers, PhD

Perm J 2012 Fall;16(4):27-30

https://doi.org/10.7812/TPP/12-028

Abstract

Objective: To describe experiences of uncertainty and management strategies for staff working with families in a hospital waiting room.
Setting: A 288-bed, nonprofit community hospital in a Midwestern city.
Methods: Data were collected during individual, semistructured interviews with 3 volunteers, 3 technical staff members, and 1 circulating nurse (n = 7), and during 40 hours of observation in a surgical waiting room. Interview transcripts were analyzed using constant comparative techniques.
Results: The surgical waiting room represents the intersection of several sources of uncertainty that families experience. Findings also illustrate the ways in which staff manage the uncertainty of families in the waiting room by communicating support.
Conclusions: Staff in surgical waiting rooms are responsible for managing family members' uncertainty related to insufficient information. Practically, this study provided some evidence that staff are expected to help manage the uncertainty that is typical in a surgical waiting room, further highlighting the important role of communication in improving family members' experiences.

Hospitals are responsible for providing a great number and variety of services in a competitive environment. Typically these services are tied to medical procedures, which, although routine from the point of view of the hospital, are unfamiliar sources of concern for patients and their families. Moreover, insurance companies and managed care firms rely on patient satisfaction surveys that include items regarding the experiences of family members during the hospital experience to make contact and reimbursement choices. Thus, remaining competitive in the market requires hospital managers to attend not only to patients' clinical needs but also to the social and emotional needs of patients and their loved ones.

Family members are likely to feel uncertain as they wait for their loved one to come out of surgery, despite attempts to create comfortable waiting spaces.1,2 Much research on waiting rooms has focused on physical changes (eg, lowering the volume of the television, having a pot of coffee available, and providing more comfortable chairs).1,3 Some studies have highlighted the important role that staff play in supporting family members through a difficult time.4,5 Communication scholars in particular have examined experiences of uncertainty in a variety of health contexts6,7 and have argued that people often experience uncertainty "when details of situations are ambiguous, complex, and unpredictable" and when "information is unavailable or inconsistent."8 Managing uncertainty is a complex challenge that research suggests falls to staff who work in the surgical waiting room.4 This case study aimed to identify challenges in managing uncertainty, if any, that staff noticed in a surgical waiting room. In addition, we sought to identify the strategies that staff used to manage the challenges they perceived family members experienced in an effort to reveal specific communication behaviors that exist in what we call the uncertainty room.

Methods

Participants

Data were collected during individual, semistructured interviews with the staff of a Midwestern hospital's surgical services waiting room. Staff included three volunteers, three technical staff, and one circulating nurse. Participants were notified about the study through an Email from a hospital director and were recruited by one of the authors (AMS). The volunteers were retired women who volunteered either three times a week or once every other week. Volunteers were responsible for speaking with families in the waiting room and escorting families to the preoperative or postoperative rooms. The technical staff had worked in the waiting room for varied lengths of time, up to nine years. The technical staff were responsible for scheduling, answering phones, and communicating with the operating room and with families. The circulating nurse acted as the liaison between the operating room and the waiting room.

Setting

In advance of our interviews, we observed behavior in surgical waiting rooms for 40 hours for background information. On the basis of visits to several hospitals, the waiting room in our study was fairly typical. The waiting room we observed was designated for nonambulatory patients undergoing a range of invasive procedures, including open heart, gastric bypass, and emergency operations. Other rooms were designated for more routine ambulatory procedures, such as colonoscopies, and yet another room was for families of patients in intensive care. Small seating alcoves made it possible to accommodate with a modicum of privacy about 50 friends or family members of patients undergoing procedures. A desk near the door served as the station at which staff could receive and disseminate information about the progress of patients' treatments. Several small consultation rooms were provided for physicians to meet with family members, but these were never used during our observations. Instead, physicians commonly spoke with friends and family members in the open public area in front of the reception desk. Reading materials and light refreshments were provided. Most people waited patiently, but a quiet sense of concern pervaded the room. It appeared that those who were waiting were monitoring patients' progress for others: cell phone calls to and from the waiting room were very common, and the most common comments were variations of, "No, she is not out yet, but I will let you know when I hear something."

Interview Schedule

Each participant engaged in one semistructured interview. We asked participants a number of open-ended questions to elicit accounts of everyday experiences in the waiting room. Follow-up questions were used to better understand participants' responses. The interview protocol contained three main sections. First, participants were asked to generally describe their role in the waiting room (ie, if s/he was a volunteer, technical staff, or circulating nurse). Participants were then asked to think about their experiences of uncertainty related to their role in the surgical waiting room. Finally, I (AMS) asked participants about the relationships between the waiting room staff and the surgeons. This analysis focuses on staff experiences of uncertainty and the strategies staff developed for managing the uncertainty they perceived family members experienced during their time in the waiting room.

Procedures and Data Analysis

This project was approved by institutional review board committees from the University of Illinois and the hospital with which we partnered. I (AMS) approached hospital staff and asked them to participate in one semistructured interview during the workday. Before each session, the purposes of the study were explained, questions previewed, and participants gave informed, written consent. Interviews ranged from 15 minutes to 30 minutes and were digitally recorded and transcribed verbatim, resulting in 57 pages of transcripts. All personal identifying information was removed from the transcripts, and pseudonyms have been assigned to narratives. As I (AMS) conducted interviews, I labeled key concepts that emerged from the data and used constant comparative analysis to distinguish patterns and themes in the data.9,10 This process allowed us to identify a key challenge for surgical waiting room staff as well as strategies that the staff developed to manage this challenge. Next, I (AMS) developed a coding scheme and applied it to the remainder of the interview transcripts. We examined the transcripts to assess the credibility of the coding scheme. The participation of multiple researchers coding the data contributes to the credibility and trustworthiness of our research.10

Results

Hospital staff noted that a major challenge to overcome in the surgical waiting room is related to communicating with families. Staff perceived that families in the waiting room do not have sufficient information about their loved one's surgery, which breeds uncertainty. Staff reported that people waiting for a loved one in the surgical waiting room had questions about the procedure that were often unanswered by the surgeon. Family members rely on the waiting room staff to communicate information that, because of hospital regulations, they cannot disclose. Participants commented that family members and friends often do not understand how long the procedure will take, from preoperative preparation through postoperative recovery. Staff suggested that misunderstandings about the length of the surgery result from communication between surgeons, waiting room staff, and family members, and nurses and volunteers have to contend with the aftermath of confusion and upset in the waiting room. For example, Jean, a volunteer, said, "We usually tell them [the families] the time of the surgery, what's scheduled" and include the caveat that "it could be less, could be more." Megan, a circulating nurse, noted that when the surgeon talks about the length of the surgery, the family members assume that they will be able to visit with their loved one after that time has elapsed. "They [the families] don't understand," she said, "why they can't go see their loved one." Hospital regulations require that surgical patients be moved to a different area of the hospital to recover after the surgery and surgeons often want their patients to come out of anesthesia before their loved ones visit, which means additional wait time. Waiting room staff reported that family members who do not receive this explanation appear to experience a great deal of anxiety about the procedure and why it is "taking so long."

Staff reported that because family members seem to have insufficient information about their loved one's operation, staff were tasked with managing the uncertainty family members experienced. Staff were able to meet the challenge of insufficient information by communicating support. Participants described several ways they were able to manage the uncertainty related to insufficient information. The obvious solution was to provide information to fill in the gaps that create uncertainty, but participants described organizational constraints that often impede staff members' ability to properly meet family members' perceived needs. The Health Insurance Portability and Accountability Act (HIPAA), for example, provides clear guidelines about what health information staff can disclose and to whom.11

Organizational constraints forced staff in the surgical waiting room to communicate support to manage uncertainty, particularly uncertainty related to insufficient information, in less obvious ways. First, providing a distraction was a way to support family members. Volunteers in particular reported that their professional identity limits the amount and type of information they can discuss with families. In other words, despite knowing that family members may be nervous about their loved one's procedure, volunteers avoid medical topics and opt to distract family members. Volunteers like Cindy "talk about things that would cheer them [the family members] up." Other volunteers described how knowledge of local events (eg, sports) helped spark conversation that served as a distraction for family members.

Reassuring family members through emotional support was another way of managing the uncertainty associated with insufficient information. In moments when emotional support seemed appropriate, staff would reassure the family that the length of time the surgeon mentioned was an estimate, and longer procedures do not necessarily portend bad news. A circulating nurse described how "once in a while you get cases that take a lot longer than anticipated, and of course that really concerns the family. They [the family] think that the worst thing they've ever heard of is happening, so you have to keep reassuring them that the patient is fine. It's just taking the doctor a little bit longer." Others echoed the importance of reassurance, describing it as "an important part of our job."

Finally, waiting room staff managed some of the uncertainty family members experienced by providing tangible assistance. Participants like Jean said they provided the families with whatever they needed, including wheelchair service, chaplain service, a place to sleep or a blanket, and someone to walk them to the postoperative floor. Something as simple as taking the time to physically walk someone to the postoperative floor, participants noted, was an important source of support, because it alleviated some uncertainty about where to go to meet the patient and placed that responsibility on the staff.

Discussion

Staff reported that families in the waiting room experience uncertainty as a result of insufficient information. Information may be insufficient because it is not provided or because the patient's family is not able to understand it. Research on uncertainty has clearly demonstrated that there are various ways in which it can be managed; at times it is appropriate to increase uncertainty, and at other times it may be appropriate to reduce uncertainty.8 This case study highlights an everyday scenario where both increasing and reducing uncertainty may be appropriate. In particular, staff roles as either volunteers or technical staff determine the type of information that they can communicate in the surgical waiting room. Volunteers neither have access to nor are allowed to communicate private patient information with the family, and they have developed communication strategies to manage uncertainty within those constraints. This has been described by other researchers in terms of the "division of labor" in health care settings.12 One of the ways that volunteers managed family members' uncertainty was distraction. Other reports have described distraction as a way to "manipulate the uncertainty of others"8 and cited examples in organizations where it is better to point someone toward the favorable or more positive aspects of a situation than to leave them to dwell on the less positive or worrying aspects.13

Staff perceived that family members do not have the right amount or type of information to manage their uncertainty as they wait for their loved one to come out of surgery, and consequently they have developed strategies to manage the uncertainty associated with waiting. These communicative strategies suggest that there are ways to improve the experience of family members in surgical waiting rooms. First, hospital managers could develop training modules for staff that describe strategies for managing uncertainty related to family members having what they perceive as insufficient information. With more research into what characterizes effective support messages, managers could highlight communication as an important characteristic of a successful waiting room environment. Second, stress associated with waiting may be mitigated by training staff to help family members acknowledge that they have questions and then use the staff's expertise. Finally, family members may appreciate advice about how to communicate their experience of uncertainty to family and to friends who are not at the hospital but feel they need information.

This case study also highlights the importance of the family member's experience, which suggests that information designed specifically for the family is essential to improving the waiting room experience. Developing a pamphlet for family members that addresses some of the concerns they may have about the waiting experience may help facilitate conversations with staff so that concerns are clearly articulated as they come up. This type of empowerment for family members has the potential to eliminate some of the frustrations that come with waiting.

There are several limitations of this research that should be addressed in future projects. First, this study relied on a small group of surgical waiting room staff. A larger sample would bolster the strength of the results and possibly allow other needs and solutions to be identified. Further, interviewing family members to outline their specific challenges and sources of uncertainty would further explicate what "insufficient information" truly means to those waiting. Future research might entail interviews with family members before their loved one is scheduled for surgery to identify any concerns they have about waiting and postoperative follow-ups to ask about their experience. Other research that accounts for the motivations and intentions of surgeons would offer an important perspective. Finally, examining other types of waiting rooms, in both medical and nonmedical settings, as points of comparison with surgical waiting rooms may allow researchers and hospital managers to develop more detailed protocols to better serve patients and families coping with uncertainty.

Conclusion

Staff in surgical waiting rooms are responsible for managing family members' uncertainty related to insufficient information. Practically, this study provided some evidence that staff are expected to help manage the uncertainty that is typical in a surgical waiting room, further highlighting the important role of communication in improving family members' experiences.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Carle Hospital, Urbana, IL, supported this project as the data collection center.

Leslie Parker, ELS, provided editorial assistance.

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