Can you hear me?' Barriers to and facilitators of communication in the presence of noise in the operating room
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Volume 34 Issue 3 Article 2
7-30-2021
'Can you hear me?' Barriers to and facilitators of communication
in the presence of noise in the operating room
Louise C. Grant Mrs
PhD Candidate, Melbourne School of Medicine, Dentistry and Health Sciences, The University of
Melbourne, Parkville, Australia., louiseg1@student.unimelb.edu.au
Pat F. Nicholson Associate Professor
Associate Professor of Nursing, Higher Degrees Research Coordinator, Course Director, Masters of
Nursing Practice (Perioperative), School of Nursing and Midwifery, Faculty of Health, Deakin University,
Burwood, Australia. Honorary Senior Fellow School of Health Sciences, The University of Melbourne
Parkville, Australia, p.nicholson@deakin.edu.au
Bronwyn Davidson Associate Professor
Honorary Principal Fellow, Department of Audiology and Speech Pathology, The University of Melbourne,
Parkville, Australia., bronwynd@unimelb.edu.au
Follow thisManias
Elizabeth Professor
and additional works at: https://www.journal.acorn.org.au/jpn
Associate Head of School (Research), Faculty of Health, School of Nursing and Midwifery, Centre for
Part of the Perioperative, Operating Room and Surgical Nursing Commons
Quality and Patient Safety Research, Institute for Health Transformation Deakin University, Burwood,
Australia. Honorary Professor School of Health Sciences, Department of Nursing, The University of
Melbourne Department of Medicine, Royal Melbourne Hospital, The University of Melbourne Parkville,
This work
Australia is licensed under a Creative Commons Attribution 4.0 License.
, emanias@deakin.edu.au
Recommended Citation
Grant, Louise C. Mrs; Nicholson, Pat F. Associate Professor; Davidson, Bronwyn Associate Professor; and
Manias, Elizabeth Professor (2021) "'Can you hear me?' Barriers to and facilitators of communication in
the presence of noise in the operating room," Journal of Perioperative Nursing: Vol. 34 : Iss. 3 , Article 2.
Available at: https://doi.org/10.26550/2209-1092.1132
https://www.journal.acorn.org.au/jpn/vol34/iss3/2
This Article is brought to you for free and open access by Journal of Perioperative Nursing. It has been accepted
for inclusion in Journal of Perioperative Nursing by an authorized editor of Journal of Perioperative Nursing.'Can you hear me?' Barriers to and facilitators of communication in the presence
of noise in the operating room
Cover Page Footnote
Funding of this research was supported by a research grant from the Australian College of Perioperative
Nurses (ACORN). The author would like to thank the health professionals working at the research site and
ACORN for their support of this research. The author would also like to acknowledge the support of this
research through the Australian Government Research Training Program Scholarship.
This article is available in Journal of Perioperative Nursing: https://www.journal.acorn.org.au/jpn/vol34/iss3/2Peer-reviewed article
‘Can you hear me?’
Authors
Louise Grant
Barriers to and facilitators of
MClinSci (Periop), RN, MACORN, MACN
PhD Candidate, Melbourne School of
Medicine, Dentistry and Health Sciences,
The University of Melbourne, Parkville,
Australia
communication in the presence
Associate Professor Patricia Nicholson
PhD, RN, FACORN
of noise in the operating room
Associate Professor of Nursing, Higher
Degrees Research Coordinator, Course
Director, Masters of Nursing Practice
Abstract
(Perioperative), School of Nursing and
Midwifery, Faculty of Health, Deakin Aim
University, Burwood, Australia. Honorary
The aim of this study was to explore health professionals’ perceptions of the
Senior Fellow School of Health Sciences,
The University of Melbourne Parkville, impact of noise on communication in the operating room.
Australia
Sample and setting
Associate Professor Bronwyn Davidson
B Sp Thy, PhD, FSPA Health professionals working in the operating room at a tertiary, affiliated,
Honorary Principal Fellow, Department major referral hospital in northern Australia were recruited using purposive
of Audiology and Speech Pathology,
sampling.
The University of Melbourne, Parkville,
Australia
Method
Professor Elizabeth Manias
M Nurs Stud, M Pharm, PhD, FAAN Semi-structured interviews were undertaken using an exploratory qualitative
Associate Head of School (Research), design to explore health professionals’ perceptions of communication and the
Faculty of Health, School of Nursing impact of noise in the operating room. Interviews were transcribed verbatim
and Midwifery, Centre for Quality and
and analysed using thematic analysis.
Patient Safety Research, Institute for
Health Transformation Deakin University,
Burwood, Australia. Honorary Professor Results
School of Health Sciences, Department
In all, 26 health professionals participated, including anaesthetists, surgeons,
of Nursing, The University of Melbourne
Department of Medicine, Royal Melbourne nurses and theatre technicians. Two themes were analysed from the
Hospital, The University of Melbourne data: barriers to communication and facilitators of communication in the
Parkville, Australia operating room. Barriers to communication focused on difficulties that health
professionals experienced when attempting to communicate in the presence
Corresponding author of noise – difficulty hearing in noisy operating rooms, positioning of health
Louise Grant professionals, and inability to filter out sounds. Facilitators of communication
MClinSci (Periop), RN, MACORN, MACN consisted of health professionals’ adaption to the presence of noise during
PhD Candidate, Melbourne School of communication – non-verbal communication, such as gestures, and the ability
Medicine, Dentistry and Health Sciences,
to filter out unwanted sounds.
The University of Melbourne, Parkville,
Australia
louiseg1@student.unimelb.edu.au Conclusion
Health professionals of all levels of experience encounter communication
difficulties. With increased experience, health professionals are able to filter
out unwanted sounds provided the OR is not too noisy. Consideration needs
to be given to the use of space and positioning of noise emitting equipment
to optimise communication in the OR. Furthermore, communication can be
facilitated by the judicious use of non-verbal communication.
Keywords: operating room, communication, noise, communication barriers,
interdisciplinary communication, health communication
e-26 Journal of Perioperative Nursing Volume 34 Number 2 Spring 2021 acorn.org.auBackground typical OR noises including quiet, by the surgeons and other team
filtered noise and background OR members who participated in the
The operating room (OR) is busy, with noise13. In another study, that used a study24.
activities such as opening paper cross-sectional design to survey the
packets and handling instruments Past research into communication in
effects of noise on work practices
and equipment, and noisy with the OR has used surveys focussing
in the OR, surgeons expressed that
phones ringing, alarms sounding, on communication between OR
they found noise distracting during
music being played and devices health professionals, quality of
OR activities such as completing
emitting noise1–6. Such noise-emitting communication during laparoscopic
the surgical safety checklist14. Two
devices may include suction, forced surgery, communication and
cross-sectional studies surveying
air patient warmers, high volume teamwork, and the impact of noise
anaesthetists found that good
suction units and the anaesthetic on OR health professionals’ work
communication among health
machine which may sound alarms. practices14–17,25. In studies where
professionals was an important
Health professionals in the OR qualitative designs were used, the
factor in delivering patient care15,
include anaesthetists, surgeons, focus was on team communication23,
and poor communication resulted
nurses and theatre technicians. When the impact of tension on
in surgical or procedural delay16. In
trying to communicate effectively, communication26, interdisciplinary
another cross-sectional study, OR
these health professionals must communication dynamics24 and
health professionals were surveyed
compete with the noise generated by communication behaviours for
on teamwork and communication,
devices and activities. When surveyed effective workplace practice27. There
with nurses explaining that a
about noise and communication, has been little previous work on
hierarchy within the health care
health professionals acknowledged how noise impacts communication.
team led to reluctance to raise
that the OR was a noisy environment Health professionals’ perceptions
concerns about patient safety issues17.
which impacted negatively on their and experiences of communicating
Past research into communication
ability to deliver patient care7. in the presence of noise needs to be
failure in the OR found the failure
further explored to enable a deeper
There are three main sources of rate ranged from nine percent18 to
understanding of communication and
noise in the OR – conversations, 57 per cent19 of all communication
the influence of noise in the OR.
equipment and music. These result events, depending on the type of
procedure, surgical specialty and the
in average sound pressure levels
phases of the surgical procedures
Aim
ranging from 55 to 70 decibels (A
weighted) (dB(A))8,9. The average observed. Communication between The aim of this study was to explore
sound pressure levels for various OR health professionals is an operating room health professionals’
types of conversation are 45 to 55 essential component of delivering perceptions of the impact of noise
dB(A) for quiet conversations9, 60 patient care, with communication on communication in the operating
dB(A) for normal conversations10 and failure negatively impacting patient room.
61 to 70 dB(A) reported for speaking safety20.
with raised voices11,12. Therefore, with Communication failure is a
Sample and setting
the diverse range of average sound common cause of adverse events The research was undertaken
levels in the OR, health professionals that originate in the OR with at a tertiary university-affiliated
would be required to raise their voice consequences including surgical hospital, which services a large
in order to be heard. count errors leading to retained rural and remote area of Northern
Past research has found that surgical products, patient harm or Australia. Participants were 205
health professionals, whether they death; wrong site or side surgery, health professionals employed in the
were undertaking a task or not, and wrong implant inserted21,22. operating suite, including surgeons,
experienced diminished ability A qualitative study identified surgical trainees, anaesthetists,
to communicate effectively with communication failure, with anaesthetic trainees, perioperative
the sound levels commonly in the information not being communicated, nurses and theatre technicians.
OR13. In their research, Way et al.13 to be a result of hesitancy and
Information about the research was
assessed the surgeon’s ability to reservation23. In a grounded theory
presented to health professionals
understand and repeat words, with study using semi-structured
during weekly meetings and followed
and without undertaking a task, with interviews, communication failure
up by email and with information
and without music playing, and with was interpreted as a lack of respect
notices placed at various sites in the
Journal of Perioperative Nursing Volume 34 Number 2 Spring 2021 acorn.org.au e-27operating suite. Further information Table 1: Topic guide for Results
was given to those who expressed interviews
an interest in participating, and a In all, 26 interviews were undertaken
mutually agreeable interview time ranging from 17 to 65 minutes with
Topic wording an average length of 29 minutes.
was organised. Interviews were
conducted in a quiet room within Ten participants were women, and
1. How do you think noise
or adjacent to the operating suite. 16 were men. The anaesthetists
impacts communication in the
Purposive sampling was used to included seven consultants and one
OR?
recruit participants from each trainee. Of the nurses interviewed,
health professional group to ensure 2. What do you think influences two were anaesthetic nurses,
representation from each group communication in the OR? four were instrument–circulating
and a wide range of ages, years of nurses and two were anaesthetic–
experience and number of years 3. Tell me about any problems instrument–circulating nurses. The
working at the research site28. you have had communicating surgeons comprised five consultants
in the OR. Can you describe and three trainees from a range of
Inclusion criteria for participating surgical specialties – ear, nose and
a situation where this has
health professionals were a throat (n = 2), general surgery (n =
occurred?
minimum of two weeks worked and 3), neurosurgery (n = 1), ophthalmic
at least one day per week working in surgery (n = 1), and orthopaedic
the operating rooms at the research The thematic analysis process surgery (n = 1). Four participants
site. Exclusion criteria were working consisted of five stages – becoming spoke a language other than English
only in the preoperative or post- familiar with the data in the at home (Table 2).
operative care of patients. transcripts, conceptualising the
Two major themes emerged
themes, applying the themes to the
Methods data, rearranging the data into the
from data analysis – ‘barriers to
communication in the presence
This research used an exploratory themes and mapping the themes31.
of noise’ and ‘facilitators of
qualitative methodology with NVivo for Mac (version 11.4.3,
communication in the presence of
semi-structured interviews to Melbourne) was used to manage the
noise’.
investigate how health professionals data during the final two stages of
the analysis process.
perceived the impact of noise on Barriers to communication in
communication in the operating Rigour during the recruitment and the presence of noise
room29. The research was granted data analysis phase was maintained
ethical approval from the research by the selection of participants, The theme ‘barriers to
site ethics committee ((2017.2801) and the use of a reflective journal and communication in the presence
the university (1749562). collaborative discussion during the of noise’ consisted of three sub-
analysis process. During the data themes – ‘hearing difficulties in
The interviews were undertaken by noisy ORs’, ‘positioning of health
the first author using a topic guide collection, the first author kept a
journal to record reflections after professionals’ and ‘being unable to
(Table 1) derived from past research7,27 filter out sounds’.
and guided by the first author’s each interview. The reflective journal
was also used to prepare for the
clinical experience as a perioperative Hearing difficulties in noisy
nurse working at the research interview to ensure no preconceived
operating rooms
site19,30. The first author underwent ideas were included in the data
training, and the other authors had collected23. During the analysis Participants expressed that their
experience in undertaking qualitative process, the data coded into each attitudes to noise changed as they
interviews with content expertise in theme were regularly reviewed grew older. A surgeon reported
perioperative nursing, patient safety to ensure the definition of each that younger health professionals
and interprofessional communication. theme was consistent throughout were still able to communicate in
Semi-structured interviews were the analysis process32. Each theme the presence of noise. However, he
audio-recorded, transcribed verbatim was discussed collaboratively with reported becoming less tolerant
and analysed by all authors using all authors to ensure consistency of noise in the OR as he aged. The
thematic analysis31, enabling themes throughout the coding process26,33. surgeon described:
to be explored and interpreted.
e-28 Journal of Perioperative Nursing Volume 34 Number 2 Spring 2021 acorn.org.auTable 2: Characteristics of participants (N = 26) to speak in a raised voice over the
noise emitted by the equipment. The
Demograhics n surgeon reported:
Anaesthetists and trainees 8 … in [a small operating room], the
scrub nurse has to be confined
Surgeons and trainees 8 to a corner because of the
Occupation arrangements of the [equipment] …
Nurses 8 So, I find perhaps the nurse has
to talk more often or speak more
Theatre technicians 2
loudly to reach the nurse on the
other end. But in [a large operating
Less than 1 year 1
room] … there is more space to
1–5 years 3 move around so you can quietly
ask the nurse whatever you need.
Number of years
6–10 years 14 (SC1)
working in OR
11–15 years 3 An instrument–circulating nurse
commented that positioning
More than 16 years 5 equipment, such as the suction
and electrosurgical units, near the
Less than 1 year 5 foot end of the OR table negatively
impacted effective communication.
1–5 years 14
Instrument–circulating nurses
Number of years at positioned near the equipment were
6–10 years 3
research site required to raise their voice in order
11–15 years 3 to be heard. This was a concern
raised by the nurses when required
More than 16 years 1 to complete the surgical count.
An anaesthetic nurse recounted a
situation affected by the position
I think younger people … in Positioning of health of the suction and electrosurgical
the operating [room] tolerate professionals units in the OR. In this situation, a
noise and seem to manage with circulating nurse was experiencing
communication. Certainly, my The layout of equipment in an OR
varied according to the room’s size difficulties understanding what the
experience has been that I was instrument nurse was asking. The
more tolerant of noise in the and physical layout and position of
items such as gas supply outlets and anaesthetic nurse was situated on
operating [room] when I was the opposite side of the OR and
younger. (SC4) power points. How the space in the
OR was used when positioning the could clearly hear the circulating
An anaesthetist, aged between 26 equipment influenced where health nurse asking the instrument nurse to
and 35 years, described that he was professionals were able to stand and repeat the request. The anaesthetic
becoming more frustrated conversing move around during surgery, and nurse described:
in a noisy OR as he grew older. thus had impact on their ability to I have noticed that if I’m over the
Another surgeon also attributed his communicate. other side [of the OR] to where the
communication difficulties in noisy [instrument] trolley tends to be …
A surgeon observed that he was
ORs to hearing loss caused by aging. They may be going back and forth
required to use the same speciality
This surgeon commented that he was with a ‘May I have this?’ … ‘What are
equipment irrespective of the size of
unaware of noisy ORs when he was you saying?’ … I can hear perfectly
the OR. This resulted in less space
a trainee; however, as a consultant well what that [instrument nurse]
for health professionals to navigate
this situation had changed and he is saying, … and I will venture over
and approach a person to converse
experienced difficulties while trying and say this is what they want.
quietly when operating in a small OR.
to communicate. (NAIC2)
Instead, a health professional had
Journal of Perioperative Nursing Volume 34 Number 2 Spring 2021 acorn.org.au e-29Being unable to filter out Facilitators of knowing the operation and getting
sounds communication in the to know each other. (SC7)
The ability to clearly comprehend presence of noise The use of non-verbal gestures to
conversations required health The theme ‘facilitators of communicate was described by
professionals to filter out some of an anaesthetic consultant when
communication in the presence of
the sounds in the OR, allowing them the OR was noisy. The consultant
noise’ consisted of two sub-themes –
to focus on conversations that were used gestures such as stern facial
‘using non-verbal communication in
necessary at the time. However, expressions or holding his finger up
the presence of noise’ and ‘being
health professionals reported that to pursed lips to request for silence
able to filter out sounds in the
when the OR was noisy, they were in the OR. Moreover, an anaesthetic
presence of noise’.
unable to filter out these sounds. trainee recalled the response she
Using non-verbal communication received when she stood up suddenly
An inexperienced instrument– in the OR with a stern look on her
circulating nurse, with limited in the presence of noise
face and projected her voice to get
working experience in the OR, Non-verbal communication was the attention of the other health
became overburdened when described as an effective form professionals in the OR. The use of
attempting to listen to all of communication when the OR non-verbal gestures enabled her
conversations occurring around her. was noisy. Participants recalled to gain their attention during the
The nurse recalled: using non-verbal gestures, either emergency. The trainee recounted:
independently or in conjunction
At the moment I’m trying to I have to admit being six foot … I
with verbal communication, and
listen to everybody. … You have just tend to have to stand up. …
specifically using their hands, eyes, or
the anaesthetists talking to their it’s your non-verbal stuff. If you
facial expressions to communicate.
students. … You have the surgeon actually are a six-foot-tall female,
speaking to the other nurse and all A surgeon recounted being able to stand up and make eye contact
the other different noises and bits use non-verbal hand gestures to with the theatre and project your
and pieces. … at the moment I’m facilitate effective communication voice so that everyone just goes
just taking it all in …, it becomes a when requesting a surgical [clicks fingers] boom. … with the I’m
little bit overwhelming. (NIC1) instrument during a surgical not joking tone … and it works quite
procedure. He stated that during a well …. I’m usually laid back, all of a
When the OR was noisy, a theatre procedure he tended to mumble; sudden, you’re – you’re a presence
technician was unable to concentrate therefore, in a noisy OR he preferred in the theatre. (AT8)
on requests made by other members to use non-verbal communication.
of the team. The technician forgot However, the surgeon qualified the
Being able to filter out sounds
the task he was asked to complete use of non-verbal hand gestures
in the presence of noise
due to the volume of noise that for communication by adding that
was occurring at the time. This this style of communication would Another facilitator of effective
forgetfulness resulted in repeated depend on the level of experience communication in the presence
communication and hindered his of the instrument nurse, whether of noise was being able to filter
ability to complete the task in a the instrument nurse was attentive out sounds in the OR. Participants
timely manner. Similarly, a surgical during the surgical procedure and reported that filtering out sounds
trainee described his experiences how often they had worked together. such as concurrent conversations
of attempting to concentrate during The surgeon reported: and equipment, including suction or
complex surgery. He related that if electrosurgical units, enabled them
I think if it is a good [instrument] to focus their attention on the tasks
the OR was noisy, he experienced
nurse and I put out my hand, at hand and essential conversations.
difficulties filtering out some of
they know what’s going on in the
the sounds which would allow An anaesthetic consultant described
operation, they know what I need,
him to concentrate on the surgical filtering out some sounds during the
so it is really nice not to ask and
procedure. induction of anaesthesia phase while
sometimes when it is loud you rely
on that more. I have a tendency to she observed an anaesthetic trainee
mumble as well. … So that comes induce the patient. The consultant
with working together for a while, explained that she did not listen to
sounds unrelated to the anaesthetic
e-30 Journal of Perioperative Nursing Volume 34 Number 2 Spring 2021 acorn.org.auphase of the procedure, such as presence of experienced OR health occupational noise-induced hearing
the call bell, which enabled her to professionals. loss to occur3,35. However, a study
communicate effectively with the undertaking audiometry testing of 22
The arrangement of equipment in
trainee. The anaesthetist recalled: senior orthopaedic surgeons, found
the OR was dictated by the type of
11 of them had some degree of noise-
I will watch the [anaesthetic surgery, door position, power and
induced hearing loss but not of a
trainee] do a whole induction … services outlets, and anaesthetist
degree to be classified as deafness38.
without noticing the [call bell] and surgeon’s preferences. Surgical
Another study undertook audiometry
going off. You are tuned into specialties need an OR of an
testing of 18 health professionals,
different things … We all ignore appropriate size for the equipment
from a range of ages and types, who
certain noises that don’t bother us required and number of health
worked in orthopaedic surgery39.
and are tuned to noises that do. professionals involved in the surgery.
This study found the exposure
(AC5) If the equipment used for the surgery
was insufficient to pose a danger
resulted in lack of space in the OR,
A surgical trainee recalled to hearing, and no noise-induced
then the circulating nurse may not
disregarding some sounds unrelated hearing loss was present in any
be able to stand near the instrument
to his role during the surgical of the participants. Moreover, the
nurse to communicate quietly.
procedure, such as the oxygen studies investigating hearing loss in
Instead, the conversations occur with
saturation alert tone. By not listening oral faciomaxillary and urological
raised voices across the obstructing
to the unrelated sounds, he was able surgeons found they were not
equipment. The noise emitted by
to concentrate on the procedure and exposed to noise levels shown to
some equipment has been identified
communicate effectively with the result in hearing loss36,37.
in past research14 as contributing
surgeon and instrument nurse. to communication failure. Past Rather than experiencing a
research found failure to meet hearing loss, health professionals
Discussion surgeons’ expectations of positioning may become less tolerant of the
This research explored how noise and choice of equipment resulted noise levels in the OR, especially
affected communication between in breakdown of communication considering the complex cognitive
health professionals in the operating between the surgeon and other tasks that they undertake. Past
room. Health professionals struggled health professionals24. However, research showed that health
to communicate effectively when the in a study of how perioperative professionals experienced
OR was noisy, revealing barriers to nurses’ practice was governed, diminished ability to communicate
effective communication including nurses became more familiar with with the noise levels present in
positioning of health professionals, the surgeons’ requirements for the OR, regardless of whether they
hearing difficulties in noisy ORs, and each type of procedure as they were undertaking an activity or
being unable to filter out sounds. gained experience working with not13. Furthermore, communication
Due to the presence of noise, health them. Through this knowledge, the was more likely to breakdown if a
professionals used facilitators of perioperative nurses were able to health professional was undertaking
communication including non-verbal try different arrangements of the complex cognitive tasks, such as
gestures and filtering out some equipment to overcome the barriers those undertaken in the OR, while
conversations and noise emitted by to effective communication posed by communicating in the presence of
equipment. However, restrictions the equipment34. noise13.
existed for when it was possible to Health professionals reported For health professionals to be able
use these facilitators. Non-verbal experiencing difficulties hearing to use non-verbal gestures as an
gestures were an effective means conversations when the OR was effective means of communication
of communication when recipients noisy; however, this may not in noisy ORs, their colleagues
understood the meaning of the necessarily be due to any hearing needed to be aware of the meanings
gestures and the context in which deficit. Past research on hearing of the gestures as well as the
they were being used. Filtering out difficulties among orthopaedic, context in which they are used. If
irrelevant conversations was also an urological and oral faciomaxillary the instrument nurse can see the
effective facilitator of communication surgeons3,35–37 found mixed results. surgical field and is familiar with the
when the noise levels were not Orthopaedic surgeons were exposed surgery, then hand gestures used
elevated or if filtering occurred in the to noise levels over the threshold by the surgeon may be an effective
level and exposure time required for means of communication. In an
Journal of Perioperative Nursing Volume 34 Number 2 Spring 2021 acorn.org.au e-31observational study of the transfer include multiple sites to expand by the judicious use of non-verbal
of objects between the instrument these findings and provide further communication.
nurse and the surgeon during insight into the barriers to and
surgical procedures40, the use of non- facilitators of communication in the Acknowledgements
verbal gestures by the surgeon was presence of noise in the OR.
Funding of this research was
an effective means of communication
supported by a research grant
when they could be observed by the Implications for practice from the Australian College of
instrument nurse. This finding was
A number of implications for practice Perioperative Nurses (ACORN). The
confirmed by another study that
have been derived from this research, author would like to thank the health
found the recipient of the gestures
relating to positioning of equipment professionals working at the research
needed to be able to see them
in the OR, the use of non-verbal site and ACORN for their support of
as they occurred41. Despite these
gestures, and consideration of this research. The author would also
restrictions, participants recounted
inexperienced health professionals like to acknowledge the support of
situations where the use of non-
and their inability to filter the sounds. this research through the Australian
verbal gestures were an effective
The positioning of equipment in the Government Research Training
method of communication without
OR is influenced by many factors Program Scholarship.
contributing to the sound levels in a
and impacts the team of health
noisy OR.
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