Surgical team: improving teamwork, a review

Abstract

Teams within surgery have been through countless cycles of refinement with an ever-increasing list of surgical team members. This results in a more dispersed team, making effective teamwork harder to achieve. Furthermore, the ad hoc nature of surgical teams means that team familiarity is not always given. The impact of this is seen across the field, with inadequacies leading to disastrous outcomes. This is a review of research that has been done into the topic of surgical teams. It will investigate barriers and consider the evidence available on how to improve the current system. Studies show an increased effectiveness of surgical teams with structures that allowed consistency in team members. The research advocates that advancements made in improving teamwork and efficiency can prove to be a low-cost but high-yield strategy for development. This can be in terms of simulated training, staff turnover management and fixed team allocation.

surgery, education & training (see medical education & training), quality in health care, medical education & training

Introduction

A dynamic process involving two or more health professionals with complementary backgrounds and skills, sharing common health goals… This is accomplished through interdependent collaboration, open communication and shared decision-making.¹

This definition of teamwork underpins every multidisciplinary and surgical team’s aims, and yet we see various examples of when this has not been the case.

Teams within healthcare have been ever-growing in size, developing in parallel to the increasing needs of the population. They are now more diverse, dynamic and dispersed than ever before, making effective teamwork that much harder to achieve. For these reasons, healthcare services are often scrutinised since inadequacies in teamwork will lead to disastrous results; the example of Mid Staffordshire Foundation Trust seems particularly relevant.² Clinical-based and ward-based cases have been extensively researched in the past; however, surgical care is yet to receive this level of analysis. For this reason, this review will focus on surgical care, in particular the surgical team.

Ward-based medicine often involves a rigid team with fixed consultants, trainees and nurses, but there still seems to be an essence of team disruption. Surgical teams, however, lack the luxury of consistency since they are constructed on an ad hoc basis, which presents a further barrier to effective collaboration.³ Despite this unfamiliarity, surgical teams are called on to deliver highly specific, effective and coordinated care using technical equipment on vulnerable populations. Surgical teams are, therefore, prone to communication breakdown, and the Joint Commission has reported that more than two-thirds of adverse events in the operation theatre were a result of poor communication.⁴ Thus, studying these dynamics within the theatre is imperative to understand how to better it.

The future directions surgery can take are boundless; whether it is the use of different equipment, new staff roles or team management, they all seek to achieve the same thing—to better patient care. Despite a lot of attention being on technological advancements, this review would like to take surgery back to its core principles: the members of the team and how to better their dynamic. The following review will focus on what constitutes a surgical team, why the current systems pose problems and what can be done in the future.

Methodology

The insights into the workings of surgical teams were gained from the Queen Elizabeth Hospital, and many perspectives were drawn on. Viewpoints from surgeons, nurses, surgical care practitioners and peripheral staff, as well as informal discussions with the patients, were accumulated to further inform the topic of enquiry.

This gave a basis for a literature search into the topic, which involved the use of PubMed, MEDLINE and the Royal College of Surgeons, among other platforms, to identify primary studies. This ensured access to high-quality, peer-reviewed journals. Inclusion criteria of literature were English-language publications between 2005 and 2017 reporting on the subject of surgical teams. Search terms used included word variations and medical subject headings major topics related to the following terms: ‘Surgical teams’, ‘teamwork’, ‘ad hoc’, ‘collaboration’, ‘operative times’, ‘barriers’ and ‘future’. Studies and reviews highlighted were initially assessed on their abstract and then on full text. This process filtered the initial results to achieve a subset of high-quality, relevant studies addressing the question at hand.

The data and conclusions from these studies were used to inform the direction of this review, and through assimilation future directions can be extrapolated. The ‘Surgical Team’ of interest to this research is considered to be the collection of staff immediately involved in the operating theatre.

What constitutes a surgical team?

Team identity

Irrespective of the differing perspectives between healthcare professionals, one theme stands out as the most consistent: surgeons are one of the leaders of the team. They influence team performance and motivation in ways that other roles could not.⁵ Typically, a surgical team will have a consultant surgeon and a trainee actively learning from them. Consultant anaesthetists will also share the prime role in task allocation, team motivation and performance guidance. Circulating nurses and ward nurses are all involved in perioperative patient care. Furthermore, scrub nurses, operating department practitioners, surgical care practitioners and in some cases specialist staff such as perfusionists are all part of the extended team.⁶ This extended surgical team shares tasks in order to combine the individual expertise of all members to optimise surgical care. This occurs through shared understanding and a respect for each other’s roles, and can only be facilitated through team and self-familiarity, which is cultivated over time.^{1  5–8}

Mental models of work will soon begin to develop and become a shared theme; this is where a mutual understanding of the intricacies of the procedure is known to all, critical points within the operation are recognised, and each other’s roles are appreciated with a common goal.⁷ This, in turn, enables quick adaptations to differing working styles to coordinate actions. The ad hoc nature of the operation theatre will seldom offer this privilege; therefore, in most cases, effective sharing of information preoperatively is more important than the familiarity between members.⁸

The various role descriptions underpin the team identity; however, identity on its own is meaningless without structure.

Team structure

An effective team is considered to have five key dimensions.⁹ These include team leadership, mutual performance monitoring, backup behaviour, adaptability and team orientation. A team structure orientated around these elements will ensure a shared mental model and mutual trust. Good leadership ensures team motivation and efficient task planning, whereby mutual monitoring identifies any resulting lapses or task overload in members. Combining this with backup behaviour, which requires the understanding of other’s roles, it allows supportive actions to be carried out for members that require it. Adaptability also plays into this notion to allow redistribution of workload as and when needed. Team orientation concerns the willingness to take other people’s goals and perspectives into account, which works best if aligned to patient care.

The structure of a team is dependent on the roles involved, and various models begin to describe this observation. The role-based coordination theory states that role responsibilities act as boundaries, and interdependence between these roles is scripted enough to function effectively in different situations.¹⁰ However, this risks the role occupants focusing narrowly on their own responsibilities and losing sight of the larger goal.¹⁰

This rigid model should be replaced by a more fluid and malleable one to reflect the nature of situations encountered. In one particular study, a programme was designed to enable on-the-fly coordination with shifting partners in care where the luxury of fixed teams is often not an option.¹¹ Normally, teams are built spontaneously; thus, the continuity of care is impinged on and not all the members of the team are familiar with one another. This study divided the emergency department in one major hospital into four pods, each of which had a fixed team of healthcare practitioners.¹¹ Each pod was independent and attended to their own queue of patients, with shifts being staggered to ensure effective handovers. Although there were staff turnovers within each team, operative performance and team behaviour were significantly improved compared with the prescaffold design. This could be attributed to the increased opportunity to cultivate relationships and trusts within each pod. The healthcare professionals held each other accountable and actively helped and updated one another. Despite this system being quite impractical in real-life emergency situations, it does warrant further investigation. However, the commitment to trial such a system has to be made by trusts and leaders from different role groups. This would facilitate the movement from a rigid ad hoc role-based system to a more predictable and collaborative one, which is arguably the next step for surgical teams.

Values of a surgical team

Condensing the above information, seven core team values can be extracted:

• Common goal: the team will revolve around a common objective, and in this case it should be the betterment of the patient. This orientates the team and avoids loss of focus.

• Know individual roles: the ability to do one’s job stems from fully appreciating what the responsibility entails. Without this, one becomes a liability to the team.

• Mutual respect and support: this allows an appreciation of other members to prevent responsibilities being ambiguous at critical points in the operation. If one knows their own limits and understands other’s, supportive measures can be taken if lapses occur within the team.

• Open communication: the idea of identifying lapses in team members and continually appraising the team’s functioning is imperative to its development.

• Morale: keeping morale high links directly with the team’s motivation to perform tasks to the best possible level.

• Work ethic: the self-efficacy of each member, maintained by high morale and good leadership, will directly impact on one’s work ethic.

• Leadership: effective leadership forms the foundation for each of the above pillars. Without a proficient and assertive leader, a team is liable to breakdown and will certainly not function to its full capacity.

Barriers to an effective team

Efficiency of an operative team can be measured by several outcomes; the most used of which is operative time. Reductions in this have knock-on effects of reduced waiting lists and reduced cost per operation. Furthermore, it has been linked to lower risk of perioperative adverse events and improved patient satisfaction.¹² It is shown that longer operative times correlate with increased risk of complications and longer postoperative recovery.¹³ Undeniably, there are a myriad of challenges to achieving a flawless surgical team, and they exist on multiple levels.

Psychological barriers

Psychological barriers may be present, with professionals being bound to their own silos and the unavoidable hierarchies that occur within theatres.¹⁴ There can be instances whereby surgeons are dismissive of other members of staff, and often can lead to an intimidating work environment. The ability to challenge colleagues in critical situations is a right that needs to be maintained; however, there are well-known failures or reluctances in this area.¹⁴ This poses its own unique challenges that negatively impact on perioperative care.

Communication breakdown

Furthermore, communication breakdown is prone to occur in impromptu, chaotic, emergency cases due to the immediacy needed with every action.¹⁵ Without a better structure, as touched on below, this will inevitably be a pitfall. In such cases, the nature of spontaneous surgical teams negates the benefit that familiarity has on outcome. This may impact communication since members may have divergent views, differing levels of experience and lack of continuity. This is especially the case when staff turnovers are involved.

Team turnover

A study investigating the impacts of team turnover and operative time concluded that nursing turnover was associated with increased operating time by nearly 1 hour.¹⁶ Turnover brings about various drawbacks; there are increased opportunities for communication breakdown during handover, the flow of surgery is interrupted, and the provision of information is subjective to those delivering it.¹⁶ To combat this, active management of surgical teams could provide a solution; staggering nursing shifts and case load organisation have been suggested to improve efficiency. These have also been shown to reduce individual staff workload, which has the potential to reduce patient risk since staff burn-out is avoided.¹⁷

Distractions

It is well known that distractions can lead to a greater strain on memory, functioning and attention span. It increases stress, and in a highly technical area such as surgery it can prove to be catastrophic. There have been notable studies investigating the presence and impacts of distractions within the operating theatre, and drawing on their conclusions a few salient points can be extracted.^18–25 Distractions were mostly initiated by external staff not directly involved with the surgery and were in the form of irrelevant conversations. However, surgeons themselves also initiated the same. It was shown that irrelevant conversations negatively impact on teamwork.¹⁸ Higher stress was associated with acoustic distractions and equipment-related distractions, all negatively impacting team working ability. It was shown that distractions can occur as frequently as 1 in every 10 min.¹⁸

The effect of collaboration and familiarity

There have been a few studies examining this phenomenon, which all yielded consistent results. Maruthappu et al²⁶ focused on perioperative outcomes in total knee replacements and correlation with surgical experience and team familiarity. Although surgical experience has been previously shown to positively impact on performance,^27–29 this study furthered this concept by investigating collective experience of the team members to build on ElBardissi et al’s study.³⁰ The results showed an inverse relationship between operative time and surgeon experience; the time declined by 51 min after 25 years of experience, but after which a plateau and a slight increase was seen. This plateau point could be explained by older surgeons with more experience being mentally fatigued, and having reduced stress tolerance and increasing complacency. Cumulative team experience had a similar impact, with reduction by 56 min for 30 years of experience being the most reduction achieved. On the other hand, mapping of operative time against team familiarity revealed a reduction with, most importantly, no plateau. Important to note is the linear relationship in team familiarity and operative times; this is a non-saturating graph which suggests that this may be a high-yielding strategy to focus on in order to make surgeries more efficient. One drawback to this study is that the cumulative experience only took into account the operating surgeons, and not the full team.

Another similar study focused on impacts of previous collaborations between attending and assisting surgeons on operative times, for reduction mammoplasties.³¹ Seven hundred and fifty-four procedures were retrospectively analysed with the mean operative times being 153 (SD=38) for no prior collaborations, 132 (SD=33) for teams with 1–5 collaborations, 116 (SD=23) for teams with 6–10 collaborations, and 119 (SD=27) for teams with more than 10 collaborations (p=0.0001).³¹ This highlighted three important findings: collaboration on previous procedures resulted in reduced operative times, this curve plateaus, and more collaborations yielded more consistent results with reduced SD. The plateau can be explained by another study³² which observed that creative abrasion (the notion of friction between two ideas) is often suppressed in cases of repeat collaboration, leading to a decline in performance.

Both aforementioned studies are retrospective, which carries with it its own limitations. This includes potential errors in data collection and recording. Furthermore, each study is only indicative of trends of respective institutions in which they are carried out; however, the similar trends observed suggest the generalisability of results.

Anaesthetist–surgeon interplay

The interplay between surgeons and anaesthetists was investigated in a study by Doll et al.³³ There were 13 632 cases analysed, and a managerial decision table was used to assign particular anaesthetists to surgeons. This resulted in a significant reduction in operative time, with designs that established familiarity between team members. This finding can be useful for trusts across the UK; it has been shown that assigning the ‘right’ anaesthetists to surgeons will increase team performance and reduce operative time. For this to be effective, each trust would need to do a similar managerial decision table to map anaesthetists to surgeons to provide theatre collaborations with the most familiarity.

Discussion

There have been many improvements in the delivery of surgical care, which range from focusing on the surgical procedure itself to changes in the surgical team. Innovations seem to be unrelenting in surgical technology, with countless new techniques and equipment being created. New members of the surgical team have also changed care delivery; for example, surgical care practitioners are now an integral part of the operating staff.

Looking to the future, educational methods have the potential to improve current practice while also being cost-effective in the long term. Focusing on educational interventions to better team dynamics would also be sustainable; surgeons and surgical staff could be trained to perform continuous situational assessments and further propagate this to future generations.³⁴ Furthermore, it is a more holistic approach to improving care since it will affect the functioning of various dimensions within hospitals, including multidisciplinary teams across all specialities. Interventions can be in the form of simulated training involving complex clinical cases and realistic tasks. Full engagement of the surgical team in such exercises will allow the shared mental models to develop. Studies on the topic have reported positive changes in communication culture and collaboration post-intervention and retention on a long-term basis.^35–38 For such interventions to be influential in trusts, a critical mass of staff need to be involved and the investment needs to be made by trust managers to implement such schemes.

Focusing on reducing staff turnover has the potential to reduce operative times and conserve resources. This may be as simple as staggering nurse shifts to reduce loss of information between staff members. This also ensures that more nurses are present when they are needed most, if shift times are coordinated with particularly busy times of the day.

On a normal day, operation theatre staff members are switched across theatres, specialties and teams several times throughout the day, which adds to the lack of familiarity within teams. No smooth workflow can be obtained in such a system. Fixing teams in an operation theatre, with a consultant surgeon and supporting staff, may present more opportunities for teams to build mutual trust. The cultivated shared mental model will help to maintain focus on the patient and help the team function more cohesively.^{27  31} Moreover, studies investigating fixed-teams yield positive results, with significantly shorter preparation, turnover time and procedure time.³⁹ Building on this notion, surgical team mapping can potentially be useful for staff allocation and coordination. Analysing staff members and case data can provide information about personnel that may informally influence team cultures and lead the development of highly functioning surgical teams.⁴⁰ It is important to note that the notion of ‘fixing teams’ has its own limitations. The team may develop behaviours against the general theatre ethos and may become more complacent. The tendency towards apathy is also a reality we face in theatres. Moreover, there would need to be a pool of staff who have experience within the team to replace any absent members when needed. This highlights the importance of nurturing new members on a regular basis to improve adaptability.

There are various mechanisms and systems in place currently to ensure cooperative teamwork in surgery, and the surgical checklist is an example. Evidence suggests that the safety checklists improved quality of teamwork and communication in theatre, resulting in reduced errors.^{41  42} In addition, such precautionary measures can be applied to reduce distractions. The concept of intraoperative pauses has been investigated in the past.^42–44 This provides opportunity for all members of surgical staff to collect themselves, brief each other about progresses made and prevent any overload of stress. It has been shown that the majority of staff were positive to a scheduled pause, and surgeons often felt refreshed. It has been reported that the pause gives time to rethink surgical strategy and collect thoughts. Pauses have shown improvements in communication and patient safety, and reductions in distractions throughout the operation.^43–45

Conclusion

Healthcare development and advancement is pivotal to provide the best care for those populations that require it. Significant resources and time have been spent on funding technological advancements, be it minimally invasive surgery or new implants, but this may not be the only direction we need to take. Focusing on improving teamwork and efficiency is a concept that requires minimal resources, but has the potential to yield incredible amounts. As studies have shown, restructuring surgical teams to increase familiarity show a non-saturating relationship with reductions in operative times.

This review has highlighted several attributes of an ideal team and fundamental areas in which teamwork can be improved in practice. This includes, but is not limited to, team communication and behaviour training, reducing staff turnover times by staggering shifts, and organising more permanent or ‘fixed’ teams. A formal cost–benefit analysis of enrolling such schemes for developing surgical teams would also be helpful to inform this field of enquiry. The studies mentioned in the review provide good evidence to warrant enrolment of such trials; however, they require further investigation to ascertain transferability to local trusts.

Main messages

• Ineffective teamwork can lead to disastrous outcomes, with communication breakdown accounting for two-thirds of adverse events in theatre.

• There are many barriers to effective teamwork, and these include, but are not limited to, unfamiliarity, psychological barriers, communication breakdown, team turnover and distractions.

• Role-based coordination theory states that team roles are scripted enough for members to function in any situation, even on an ad hoc basis, and this model may be too rigid to reflect the nature of situations encountered in theatres.

• An effective team consists of five key dimensions: team leadership, mutual performance monitoring, backup behaviour, adaptability and team orientation.

• Increasing team familiarity will cultivate shared mental models, and this ensures a smooth flow of the operation since all members are familiar with key stages.

• Efficiency can be improved if the team members are familiar with each other, and structures that promote this have had the best results in terms of operative time and adverse outcomes.

Current research questions

• What are the financial implications of enrolling simulated team training and educational interventions, and what are the benefits? A cost-effective analysis will be useful to inform this enquiry.

• What are the issues (ethical and otherwise) of using surgical team mapping as a technique to increase efficiency?

• How realistic is the idea of ‘fixing’ surgical teams? A qualitative insight into what healthcare professionals think would be a useful perspective to gain.

Key references

The core principles of teamwork:

• Salas E, Sims DE, Burke CS. Is there a “Big Five” in teamwork? Small Group Res 2005;36:555–99.

Introducing a structured model for the emergency department:

• Harvard Business Review. Improving On-the-Fly Teamwork in Healthcare. (internet), 2017. Available at: https://hbr.org/2016/11/improving-on-the-fly-teamwork-in-health-care [Accessed 5 Dec 2017].

Impacts of distractions:

• Wheelock A, Suliman A, Wharton R, et al. The impact of operating room distractions on stress, workload, and teamwork. Ann Surg 2015;261:1079–84.

Team familiarity and efficiency:

• Maruthappu M, Duclos A, Zhou C, et al. The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis. J Royal Soc Med 2016;109:147–53.

Team mapping and staff allocation:

• Sykes M, Gillespie B, Chaboyer W, et al. Surgical Team Mapping: Implications for Staff Allocation and Coordination. AORN J 2015;101:238–48.

Self assessment questions

• Shared mental models of work will develop with increased familiarity between team members. This can only be done if critical points within each operation are known to all.

• Role-based coordination theory is a thorough model that can effectively script the nature of surgical cases, and therefore governs how team members should behave. This allows ad hoc teams to work as effectively as those teams that have familiar members.

• Team members with familiarity form more effective teams since there are more opportunities to cultivate relationships and trust, which again feeds into the notion of shared mental models.

• Studies have shown that for increasing number of collaborations of surgical staff, there is a reduced operative time; however, there is a greater spread of times seen.

• Surgical team mapping, whereby staff members and case data are analysed in order to allocate teams, has the potential to lead the development of highly functioning surgical teams.

Answers

• True. This will enable teams to work more cohesively with a common objective. It will ensure teams work together effectively despite their differing working styles.

• False. The role-based coordination theory is a rigid model which is not malleable enough to reflect the nature of situations encountered in surgery. There is also a risk of team members focusing too narrowly on their own roles, thus negatively impacting teamwork. Furthermore, familiar teams have in fact been shown to positively impact effectiveness.

• True. A study by Harvard Business Review introduced fixed teams in an emergency department, showing positive results.

• False. Xu et al conducted a longitudinal study investigating this relationship, and the results have shown that more collaborations result in reduced operative times (however this plateaus) and more collaborations yielded more consistent results.

• True. Sykes et al conducted a study addressing the indications of this notion and concluded that the model has the potential to positively impact effectiveness.

Footnotes

Contributors

HK and RM have seen and agreed to the submitted version of this academic piece. HK and RM made substantial contributions to the conception of the work. The authors were responsible for acquisition and analysis of relevant data, and both HK and RM were involved in drafting and revising the paper critically. The paper has final approval from the stated authors. The authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Furthermore, the authors confirm that the manuscript is original and has not been previously published. If accepted the report will not be published elsewhere in the same or similar form, in English or in any other language, without written consent of the copyright holder. I wish to thank Dr. Manish Sonsati, as this piece could not have been written without his advice, patience and general support.

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests

None declared.

Patient consent for publication

Not required.

Provenance and peer review

Not commissioned; externally peer reviewed.