critical thinking in the operating room

Developing critical thinking in the perioperative environment

Affiliation.

• 1 Wellstar School of Nursing, Kennesaw State University, Kennesaw, GA, USA.
• PMID: 20152198
• DOI: 10.1016/j.aorn.2009.09.025

Critical thinking is considered an essential skill for nurses by many, including major accrediting agencies, health care administrators, and AORN. This is in part because of the environment in which nurses function. Health care, medicine, technology, and nursing are dynamic and constantly changing. The perioperative environment is complex, fast paced, unique, and oftentimes unpredictable. Critical thinking skills enable perioperative nurses to function effectively and evolve in this ever-changing environment. Nursing education programs are mandated to teach critical thinking skills. It is the practice arena, however, that refines, hones, and grows these skills. This article provides an overview of critical thinking in the context of nursing, as well as strategies and interventions designed to teach critical thinking skills.

Copyright 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Publication types

• Case Reports
• Attitude of Health Personnel
• Cholecystectomy, Laparoscopic / nursing
• Clinical Competence*
• Education, Nursing, Continuing
• Health Facility Environment / organization & administration
• Middle Aged
• Nurse's Role* / psychology
• Nursing Process / organization & administration
• Operating Room Nursing* / education
• Operating Room Nursing* / organization & administration
• Operating Rooms / organization & administration
• Preceptorship
• Problem-Based Learning

• Research article
• Open access
• Published: 19 May 2020

Managing complexity in the operating room: a group interview study

• Camilla Göras 1 , 2 , 3 ,
• Ulrica Nilsson 4 , 5 ,
• Mirjam Ekstedt 6 , 7 ,
• Maria Unbeck 4 , 8 &
• Anna Ehrenberg 1  

BMC Health Services Research volume  20 , Article number:  440 ( 2020 ) Cite this article

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Clinical work in the operating room (OR) is considered challenging as it is complex, dynamic, and often time- and resource-constrained. Important characteristics for successful management of complexity include adaptations and adaptive coordination when managing expected and unexpected events. However, there is a lack of explorative research addressing what makes things go well and how OR staff describe they do when responding to challenges and compensating for constraints. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses, registered nurse anesthetists, and surgeons, and how these professionals adapt to create safe care in the OR.

Data for this qualitative explorative study were collected via group interviews with three professional groups of the OR-team, including operating room nurses, registered nurse anesthetists and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. The audio-taped transcripts were transcribed verbatim and analyzed by inductive qualitative content analysis.

The findings revealed three generic categories covering ways of creating safe care in the OR: preconditions and resources , planning and preparing for the expected and unexpected , and adapting to the unexpected . In each generic category, one sub-category emerged that was common to all three professions: coordinating and reaffirming information , creating a plan for the patient and undergoing mental preparation , and prioritizing and solving upcoming problems , respectively.

Creating safe care in the OR should be understood as a process of planning and preparing in order to manage challenging and complex work processes. OR staff need preconditions and resources such as having experience and coordinating and reaffirming information, to make sense of different situations. This requires a mental model, which is created through planning and preparing in different ways. Some situations are repetitive and easier to plan for but planning for the unexpected requires anticipation from experience. The main results strengthen that abilities described in the theory of resilience are used by OR staff as a strategy to manage complexity in the OR.

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Clinical work in the operating room (OR) is dynamic, and complex, and often time- and resource-constrained [ 1 ]. Performing surgical procedures requires, specific technical and cognitive skills from OR staff, such as anticipating patients’ needs, managing changes and handling unexpected events [ 1 , 2 ]. Increased co-morbidities of patients [ 3 ], and pressure for efficiency and productivity [ 4 , 5 ] are other challenges that may influence the work in the OR. Teams in the OR interact, communicate, adapt, learn and self-organize over time [ 6 , 7 ] which are common determinants of a complex adaptive system (CAS) [ 7 ]. From the perspective of complexity there are different strategies for improving patient safety, from attempting to control complexity to embracing it by encouraging flexible behaviors [ 8 ]. Complexity requires to wisely balance thoroughness and control with flexibility and adaptations [ 9 ]. The surgical safety checklist [ 10 ] is an example of a procedure that structures safe care processes in the OR that lay ground for patient safety which also can include flexibility in the face of unpredictable events. Complexity means that work processes may be disturbed or interrupted by unpredictable events that the OR staff has to adapt to and handle [ 11 ]. Adaptations contribute to keeping the system’s performance at an acceptably high level under both ordinary and extraordinary conditions, but can also create high-risk situations [ 12 ]. According to the coordination and mobilization of many interdependent processes, support and resources in a CAS are seldom optimal which may produce strain among staff and lead them to develop compensatory strategies [ 13 ].

In the attempts to understand and influence how complex systems such as OR works, traditional ways of thinking in forms of linear causality models are insufficient. A ‘system thinking’ approach that consider the flow of interactive activities (e.g. between people, equipment, procedures) and the continuous adjustments needed to cope with system variability can help to improve safety and performance in the daily practice in an OR [ 12 ]. Patient safety in the OR should be understood by studying “work-as-done”, which reflects the reality that professionals have to deal with in their everyday clinical work, rather than through the ideal picture of “work-as-imagined” which is often presented in policy documents or action plans [ 12 ]. However, a deeper knowledge is needed to understand how “the work is described as being done” in relation to safe care in the OR.

Strategies to cope with and adapt to complexity have been described from the perspective of Resilience engineering, RE [ 14 , 15 ]. Resilience is defined as the ability of the healthcare system to adjust its functioning prior to, during, or following changes or disturbances, so that required operations can be sustained under expected and unexpected conditions [ 16 ]. From a RE perspective, rather than controlling what professionals do, patient safety is strengthened by a systemic capacity which enables professionals to be reflexive, to adapt to changing conditions, and to understand the whole system [ 14 ]. Resilient organizations is often described through four abilities: the ability to respond to events, to monitor ongoing developments, to anticipate future threats and opportunities and to learn from past failures and successes [ 16 ]. Resilience research has shown that ways of managing complexity are also characterized by abilities such as anticipation, sensemaking, trade-offs, and adaptation [ 17 ]. Operationalization of resilience in inpatient healthcare is characterized by professionals anticipating and bridging gaps by proactively monitoring and acting on problems [ 18 ]. Adaptive coordination, the ability of a team to change its coordination activities in response to unexpected events and varying task characteristics [ 19 ], are other cornerstones of effective team performance in complex settings [ 20 ]. Preoperative huddles have shown to contribute to improvements in patient safety, communication, and teamwork. Postoperative debriefings after non-routine and routine cases are other strategies that stimulated learning, and improved work processes and teamwork [ 21 ]. Behaviors to manage non-routine events in the OR are also described to include task- and information management, teaching, and leadership [ 19 ].

To cope with complexity, that is managing expected and unexpected events, resilience has been described to be important. When managing unexpected events in the OR adaptive coordination was described an important skill. However, there is a lack of explorative research addressing what makes things go well and how the OR staff describe they do when responding to challenges and compensating for constraints. This can be understood by describing how health professionals describe that work is done in a clinical setting. Knowing how surgical teams manage complexity will be an important contribution to a deeper understanding of how patient safety is created in a collaborative way in the OR. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses (ORNs), registered nurse anesthetists (RNAs), and surgeons, and how these professionals adapt to create safe care in the OR.

Setting and sample

This study employed a qualitative explorative design by using group interviews with OR staff. The interviews were conducted at two central OR departments at one county hospital and one local county hospital in mid-Sweden. Each hospital had one department for day surgery and one central OR department. The central OR department at the local county hospital served both acute and elective surgical and orthopedic patients, whereas the OR department at the county hospital in addition also served gynecological patients. Teams in Swedish ORs commonly comprise six different professionals: ORN, operating surgeon (surgeon), assisting surgeon, circulating nurse (commonly a licensed practical nurse) anesthesiologist and RNA. In Sweden, RNAs are allowed to maintain anaesthesia with direct or indirect supervision of the anesthesiologist [ 22 ]. The sample consisted of three professional groups of the OR-team, including ORNs, RNAs and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. Two ORNs at the county hospital, who participated in the pilot interview, were included, to achieve large enough group sizes. The four groups comprised a convenience sample of professionals who were available to be released from clinical work and who had been employed at the OR for least 6 months. The interviews were conducted at separate occasions divided in groups by professional specialization. The informants’ characteristics are given in Table  1 .

Data collection

Open questions were asked based on an interview guide which had been developed by the researchers. The interview guide was pilot tested and resulted in a minor rearranging of the themes, but no revisions or changes in content were needed. The interview guide consisted of five questions including “Can you tell me how you plan your day at work?”, “Could you tell me about situations when the work proceeded according to plan?”, “Could you tell me about situations when work did not proceed according to plan?”, “What enables and what hinders you from being able to do the work as planned?”, and "Do you ever have to abandon routines. To get permission to conduct the study, information was provided both verbally and in writing to the medical director of the surgical department and nurse managers at the OR department who invited their staff to participate. Those who volunteered gave their written informed consent after receiving verbal and written information including the voluntary nature of participation and the ability to withdraw at any time without further explanation, and confidential treatment of data.

The data were collected during February and April 2018, via scheduled 1-h interviews in an undisturbed and quiet location at the workplace. At the beginning of each session, the moderator and the assistant (i.e., the first and last authors) gave a brief presentation of the study, including the aim of the study and why the participants were selected. The discussions were led by the same moderator (first author) throughout all four interviews. The interviews were audiotaped, and field notes were taken by the assistant. The interviews lasted between 50 and 59 min and were transcribed verbatim.

Data analysis

The interviews were analyzed by using inductive qualitative content analysis focused on the manifest content [ 23 ]. All the authors are registered nurses or RNAs with experience of healthcare and the OR, and all participated throughout the analytical process to identify codes, sub-categories, and generic categories. Transcripts were read thoroughly several times to obtain a sense of the whole. Content that related to the aim of the study was noted first in the margins of the text and then on a coding sheet. The codes were based on similarities and differences and were sorted into sub-categories which were then interpreted and aggregated into broader generic categories. The different steps were discussed within the research team. To maintain consistency, there was a movement back and forth between the transcripts, codes, sub-categories, and generic categories. To reach consensus, the research group independently categorized the codes and discussed the findings several times. The analysis generated three generic categories. An example of the analytical procedure is presented in Table  2 .

When analyzing the group interviews three generic categories emerged from the sub-categories of each professional group: preconditions and resources, planning and preparing for the expected and unexpected, and adapting to the unexpected. In each generic category, one sub-category was common and shared between the three professions: coordinating and reaffirming information, creating a plan for the patient and undergoing mental preparation, and prioritizing and solving upcoming problems as displayed in Table  3 . Subsequently the generic categories with specific sub-categories representative for each profession follows.

Descriptions of how safe care is created shared by three professional groups

Preconditions and resources, coordinating and reaffirming information.

Coordinating and reaffirming information was a sub-category that emerged as common to all three professions. If critical situations or changes in patient conditions occurred, communication was described as central to creating safe care. Having the same information was also considered essential for a well-functioning surgical teamwork. When a change of plans was called for, the ORNs often used communication with external support services such as coordinators at the OR department to convey information, get support, and obtain new equipment. When issues occurred regarding surgical instruments, the ORNs expressed communication with the surgeon to be important in order to allow prioritization and planning. The surgeons said that they interpreted communication depending on their understanding of the urgency of the situation, which helped them to prioritize. Safe communication was perceived by both ORNs and RNAs to be easier in a small workplace with shorter information paths. The ORNs said that when the team was less integrated, communication within the sub-team (e.g. ORNs and surgeons) was even more important for safe care:

“Communication is more important when the team is not well integrated. That applies to talking to each other, who does what, and what do you need help with, so you don’t get parts of the team taking it for granted that others are doing it.” (ORN)

For the RNAs, an essential precondition was the ability to get access to colleagues quickly by having a telephone nearby. From the surgeon’s perspective, communication was a prerequisite for conveying difficult moments during surgery that required an increased focus from the entire surgical team.

Planning for the expected and unexpected

Creating a plan for the patient and undergoing mental preparation.

An important sub-category common to all three professions emerged as creating a plan for the patient and undergoing mental preparation. In order to be mentally prepared, the professionals created a plan for the patient before the procedure. They read about the patient individually or together to create a mental model and a shared plan. From identified potential patient risks they planned what might be needed for that patient and procedure. The ORNs described how they planned and prepared for equipment adjustments prior and during a surgical procedure, based on the individual needs of both the surgeon and the patient:

“It’s based on what’s best for the patient — to ensure that the surgery will be as good as possible. Don’t hurt the patient. How does it look, what are the things you have to watch out for when you use leg support — we’re thinking about that all the time.” (ORN)

While much of the work was standardized, it was then supplemented after the ORNs had created their mental model or seen the patient. The RNAs anticipated what could happen and adjusted the plan for the patient. The plan was also communicated and structured together with the anesthesiologists, based on the anticipated scenarios. The surgeons said that in most cases they knew the patient, when this was not the case, they created a mental model of the patient and the procedure by consulting the patient record and talking to the patient:

“Often you’ll already know the patient, but if you don’t then you read the patient record and create a mental picture of them.” (Surgeon)

For the RNAs to be mentally and practically prepared clinical experience emerged as a crucial underlying prerequisite. The RNAs described a standardized routine and workflow in which information was obtained from different systems, including reported patient status by the ward nurse. Preoperatively, they also anticipated possible scenarios by inspecting and talking to the patient. Hence, possible scenarios could be identified and anticipated in advance:

“Yes, you’re prepared for it ... You might ‘read’ the patient and understand that this isn’t going to work. Like, I can see that 82-year-old Agda hasn’t had anything to drink since noon yesterday, so she’s already dehydrated…a large surgical intervention, and then when I’m positioning her I find candy under her pillow. I mean, then it’s a completely different scenario.” (RNA).

The RNAs argued, if they planned and prepared carefully in advance this was not a problem:

“Otherwise, once the process has started things just keep rolling. And you’ve, like, created this whole plan for the patient. That’s why we plan — so that won't happen.” (RNA)

Adapting to the unexpected

Prioritizing and solving upcoming problems.

Adapt to the unexpected, by prioritizing and solving upcoming problems was the third sub-category that emerged as common to all three professions. When unexpected issues occurred during a surgical procedure, both RNAs and ORNs said that they assessed the risks against the benefits and adapted to the situation. The ORNs expressed that prioritizing the saving of life over ensuring sterility was an important strategy for safe care:

“Sometimes you can’t scrub the patient — life is more important than ensuring sterility, and you can deal with that later. If an infection occurs, you have to treat it then. For example, we don’t scrub the urgent Cesarean sections, or the ruptured aortas when they arrive directly from the emergency room. Those aren’t the times to argue if someone comes in in white clothes, without a surgical cap and coat.” (ORN)

When problems and issues occurred during surgery, the surgeons and the RNAs expressed that problems had to be solved and it was not an option to allow things to go wrong. Surgeons described that consultation took place with more experienced colleagues or specialized hospital clinics. The problem had to be solved, and inaction was not an option.

The ORNs said that when unexpected equipment-related issues occurred, they checked the equipment, asked for a replacement or handed the problem over to a colleague and continued to focus on the surgery without being affected. The surgeons said they prioritized the interruptions that were perceived as urgent. For the RNAs, intraoperative changes in patient status were anticipated by monitoring trends in the patient’s vital signs, which allowed them to be prepared and hence respond quickly to changes. Being flexible and responsive was one of the RNAs professional skills and perceived as an inherent ability of an RNA. The RNAs explained that when facing changes or challenges they adapted to the new situation and asked for help from their colleagues. To adapt, they used previously created plans B and C, as a part of their mental model when preparing for the procedure:

“It’s the planning ahead, you plan the surgical procedure. As I said, experience from this or that can happen, but then you have a plan B. Perhaps you also have a plan C as well, as it’s like … it’s people, and it can’t go wrong, you have to handle it.” (RNA)

The surgeons perceived that working in the OR meant having to be prepared for changes and variations that sometimes contributed to a lack of focus. Unexpected urgent procedures were taken care of ad-hoc in the work process. Handling this required flexibility, adaptation, prioritization and the ability to relate to variation, interruptions and disturbances. Everyone in the care process, including staff on the wards as well as staff in the OR and recovery, had to be flexible because changes could affect everyone. Some considered variations challenging, but being able to handle a complex workday was also a positive experience which helped make the work enjoyable and stimulating:

“Or is it that they, like most of us, love their work, so it’s more a positive challenge to, like, hit the volley, I think.” (Surgeon)

Preconditions and resources from the perspective of each profession

Orns’ perspectives, team coordination.

The ORNs described team coordination as a precondition for safe care. Familiarity with the team was described as providing security. When assisting surgeons, interaction and detection of the situation ahead were perceived as important. Cooperating with and supporting less-experienced surgeons were described as a significant part of their responsibility.

“After all, there are constantly new surgeons from different specialties who also need support, to make them feel safe and that they are moving forward, which is actually something I would say that is part of our profession. If we just stand there and wait, are grumpy, and turn our backs, the operating time extends. But when you have the flow, “a dream team” as you say, then it's wonderful.” (ORN)

The preconditions were also described as focused on the closest team members (surgeons and circulating nurse), the patient, and the assignment, as well as interacting and having a common goal.

Having experience

The ORNs saw experience as a resource, crucial for maintaining safe care in the OR. Being aware of one’s limitations and increased experience was said to make it easier to get a sense of the whole surgical work process. Different levels of responsibility were given to the other members of the team based on their experience. The less experience the circulating nurse had, the more responsibility was perceived to be placed on the ORN. Decision making seemed, by the ORNs, dependent on experience by making it easier to make decisions, speak up, and follow the plan. The ORNs said that if issues arose, they could always use their experience to find a solution:

“We solve problems; we see them as a challenge. Problems are there to be solved. Do the best thing possible. We now have the advantage of having so much experience that we don’t get stressed about it — we always have a plan B.” (ORN)

The ORNs also described how they gained experience by discussing and reflecting on a situation retrospectively with the other team members and learning from prior situations and decisions.

RNAs’ perspectives

Maintaining focus.

The RNAs said that there were many disturbances during surgical procedures. Staying focused was perceived important. To stay focused, they did not let themselves be disturbed, by conveying when it was not appropriate to interrupt and continuing with the ongoing task:

“When it comes to induction of anesthesia and the awakening, those are the sensitive phases. We can’t have people running in and out of the OR, giving a lot of information, or asking for a change. That’s when there needs to be a little more focus. Those are the situations when we’re in an extra sensitive phase, I think.” (RNA)

Surgeons’ perspectives

Having respect for the team and shared goals.

Respect and cooperation were considered preconditions for a well-functioning team, and the most essential prerequisite for the work in the OR:

“The team is everything. You go there to help and not to counteract each other. It has to do with respect and cooperation and all that.” (Surgeon)

Surgeons considered familiarity within the team and helping each other as a precondition for a smooth surgical workflow. Having a common goal and focusing on the patient were perceived to create the conditions for getting the job done properly. The surgeons also described a small “team within the team” comprising the operating surgeon, the assisting surgeon, and the ORN. With a well-functioning small team, they perceived themselves to be less disturbed by what was happening around them. It was important to respect the function of the team. Understanding and showing respect for one’s colleagues and recognizing that everyone was as important for the team despite having different tasks were described as prerequisites for safe care.

Having experience and competence

The surgeons described how they were trained from day one to handle interruptions and disturbances, which were perceived as expected and normal. They were prepared for unexpected events to occur and knew that they would have to handle the changing situation. When they were interrupted or disturbed during surgery and then continued with the primary task, it took a while to get used to these changes. However, all these abilities were linked to professional experience and would come with time:

“For that reason, I think the longer you work, the less disturbed you get, or you find some strategy for dealing with it.” (Surgeon)

As well as experience, high competence in the organization was described as an important precondition for safe care . Professional competence and training were important preconditions that had to be ensured by the management.

Maintaining focus and creating space for mental rest

Maintaining focus was considered an important ability, and the surgeons described several strategies to achieve this. When there was a high level of disturbance and noise in the OR, they tried to ignore it by staying calm, resisting, and staying in the “bell jar”. If, in spite of this, they were disturbed to the point of losing focus, they would speak up. For them to lose their focus, the interruption had to be of high urgency:

“It’s easy to say, but you have to brace yourself and stay hyper-focused. You don’t leave that state of extreme focus unless it’s something very important and relevant.” (Surgeon)

In order to maintain focus while still being able to adapt to the unexpected events that can occur during surgery, the surgeons described that they took care of unexpected issues ad hoc along the way. The strategy was to avoid cognitive overload that would consume energy. To maintain focus, they took small mental breaks; experienced surgeons said that they could do this without anyone noticing.

Planning and preparing for the expected and the unexpected per profession

Checking and having control to be prepared.

The ORNs considered preoperative control crucial for safety and security. To be able to plan for the expected, they described several operational checks prior to surgery including functional tests and checking of settings, the amount of gas, and availability of other material and equipment. When applicable, the marked operating area on the patient was checked, and paired organs were double-checked with radiographs and verified with the patient . To maintain awareness of the patient’s condition intraoperatively, the ORNs continuously observed the activity within the anesthesia team, such as looking at monitors, or calling on a colleague for support, as this was an indication of the patient’s status. Much of the preoperative preparation was performed by other ORNs or circulating nurses. For responsible ORNs to be prepared they had to check that the instruments, materials, and supplies were adequate. Counting and checking the sterile instruments and surgical tissues continuously during the procedure was another strategy described by the ORNs. To retain control, the surgeons were not allowed to pick up their own sterile instruments from the medical instrument stand. Being prepared and knowing that everything was in order before the surgeon arrived and being one-step ahead of the intraoperative process was important strategies described by ORNs. When working with new employees, the ORNs were more vigilant and prepared, as they did not know what to expect from the new colleague. However, they recognized the person’s capacity and prepared themselves mentally to provide support when needed:

“Interaction — get a sense of who the person is and give them a chance. But don’t retract those sensitive antennae — extra preparedness.” (ORN)

Taking support from roles and routines

When planning for the expected and unexpected, the ORNs described that they used routines and tools when preparing instruments for the procedure that existed in the OR to support their work.

“We have a lot of tools, routines, index cards, positioning guidelines — everyone has their position and knows what to do.” (ORN)

Adhering to policies and procedures, was important to reduce unnecessary interruptions or disturbances. The ORNs also described the importance of the different responsibilities of the professions in the surgical team. For example, when problems with equipment occurred, they often asked the circulating nurse for assistance as they were more skilled in handling the medical technical equipment.

Creating a basic plan for work

The RNAs described that they checked which OR they were placed in and the team members of the day, and then created a tentative plan of what could happen during the day .

“I might start by checking out the daily OR schedule in paper form, the number of procedures at this moment and what kind of procedures. Which team members, which ORN, which circulating nurse and maybe which anesthesiologist I should contact.” (RNA)

By looking at the OR schedule for the day, they could also anticipate potential changes in the schedule.

Checking and restoring

Another way the RNAs planned for the expected and unexpected was to conduct several pre-surgery operational checks including functional tests and checking settings and intended anesthesia equipment.

“Yes, you go through the trolley with all anesthesia equipment, locate what you need, and bring it out so it’s ready — then you can quickly see.” (RNA)

The RNAs also described how the team preoperatively checked the patient’s skin quality to prevent surgical site infections. When restoring the room after surgery, and to be prepared for acute surgery it was important to check and refill all the supplies that had been used.

Creating and re-evaluating a basic plan for work

The surgeons also said they created a basic plan to be prepared and plan for the expected and unexpected.

“There’s also a basic plan, but you sort of figure out the day as it develops, and no day is like another, which is also nice — variable and revitalizing I think, compared to many boring industrial jobs.” (Surgeon)

The preparation phase started the day before, when the surgeons thought about what could be expected and how they would get things done. On the day of surgery, they checked the OR schedule again as it might have been changed. Making a rigid long-term plan was not feasible, as the plan would be verified and re-evaluated several times during the day. This was perceived as an appropriate strategy when working in an unpredictable context such as the OR.

Using guidelines and routines but with certain degrees of freedom

The surgeons explained that following routines and using guidelines was important for being prepared, creating a good workflow, and reducing unnecessary interruptions and disturbances during surgery. However, sometimes a deviation from routine could be necessary:

“Routines are built from standard flows. Then you also have urgent situations, but they also have routines, right? So you can know what’s coming — at a certain interval this or that will happen and we have routines for it. But in every situation, you also have to be able to improvise. It’s like those Russian ice dancers — the more they practice, the more they can improvise.” (Surgeon)

The main results show that to manage complexity and create safe care in the OR, the professionals shared experiences that certain preconditions and resources were crucial, including having work experience and coordinating and reaffirming information. More specifically, resilience was expressed in the professional’s capacity to prepare, respond and adapt to expected and unexpected situations. By creating a common mental model of the patient, the team established readiness to anticipate, prioritize and solve upcoming problem during the surgical procedure.

The challenges, fragility, and unpredictability of working in a CAS have been described as time- and resource constraints in the OR [ 13 ], and gaps in continuity of care, such as lack of information or communication between professionals in handover situations [ 24 ]. Why most things go right, has been proposed to be pertaining to professionals ability to accomplish their tasks by adaptations and work-arounds [ 6 ]. One common precondition for safe care was expressed by the three groups as coordinating and reaffirming information. A previous observational study, that studied how work was done, found that communication was the most common task involved in multitasking [ 25 ]. The results of the present study show that professionals described communication as an important for achieving a safe and smooth care process and may reflect the challenges that comes with working in a CAS. Speaking up may fuel resilience, from a safety culture perspective [ 26 ] members of a surgical team must have the right speak up about a perceived risk or transfer of patient information [ 27 ]. Communication has been described as comprising important transfer of information between professionals, contributing to a safe, seamless, and efficient care process in the OR. In other situations it may cause interruptions resulting in non-completion of tasks [ 28 ] or gaps in continuity of care [ 29 ] that in turn may have a negative impact on patient safety. Good outcomes have been proposed to be related to the systems adaptive capacity, the individuals, teams’ and the managements’ ability to adapt to unexpected events and changing situations, for example by using interaction and communication [ 30 ]. With a focus on how work was done in a context with variable complexity, an ethnographic study explored communication and relationship dynamics in surgical teams. Proactive and intuitive communication, silent and ordinary communication, inattentive and ambiguous communication and contradictory and high dynamic communication were identified. Different types of team collaboration were connected to the level of complexity of performed surgical procedures [ 31 ]. From the perspective of a CAS, communication is crucial for having the right preconditions to create safe care, adapt to unexpected events and creating effective team interactions and coordination. Teamwork and shared mental models are also considered crucial for patient safety in dynamic domains such as the OR [ 32 , 33 ]. Communication allows a greater understanding of potential risks to develop [ 6 ] within the team, as the different professionals share their mental models [ 32 ] of the situation and ways to anticipate and be prepared to respond to system failures. A flat hierarchy seems more likely to manifest a well-functioning team communication [ 34 ].

The professionals also expressed that clinical expertise [ 30 ], experience and competence, were important individual resources to be able to plan and to meet the unexpected. According to surgeons, experience as well as organizational competence was described as an important precondition for safe care. Experienced colleagues were perceived by ORNs, as being more aware of the other team members’ capacity, competence, and need for support which made it easier to make decisions, speak up, and follow the plan. In line with other studies in the OR [ 19 , 35 , 36 ] the RNAs’ work experience was perceived as important for having the cognitive ability to anticipate risks, planning for the expected and unexpected, and be prepared both mentally and practically for the surgical procedure. Participants in this study had quite high mean experience which may predispose for degrees of freedom to be flexible and adapt to situations and opportunities are easier to be seen. From a theoretical perspective, experience seems a crucial component in handling the unexpected. Resilience does not merely emerge in response to specific disturbances, but develops over time from a continuous training in managing and learning from risks, stresses, and strains [ 37 ]. Mental models play a central role in individual’s behavior and sustained learning based on both one’s own experiences and those of other team members [ 38 ]. Sensemaking, retrospective and prospective learning, that is arriving at a common understanding of a situation in order to adapt to and handle it adequately evolves during communication where professionals share their expertise and knowledge [ 39 ].

When planning and preparing for the expected and unexpected, it was during these processes mental models primarily were created. This was described as collecting relevant information, anticipating potential risks, and talking to the patient. This is in line with sensemaking, a social process [ 30 , 40 ], usually triggered when the team is facing an uncertain situation. It is a retrospective skill with focus on achieving plausibility, dependent on previous situational experience [ 41 ]. The same skills involved in using past experiences to find a pattern in a sensemaking process can also be used to proactively anticipate and prepare for situations that may arise. Prospective sensemaking is described as building the capacity for anticipation, which enables smooth collaboration and preparation for coping with undesired but foreseeable situations related to patient safety. Important interactions with technology in the OR have been described as prospective sensemaking, a sociotechnical process central to capturing the dynamic work in the OR supported by social and technological resources. The surgical team were shown to be constantly aware of emerging risks and were thus prepared for a rapid response [ 36 ]. Anticipating, or knowing what to expect, is also a cornerstone of resilience [ 16 ]. To some extent, planning was described differently by the three professions. The ORNs’ primary focus was on the surgical instruments, while the RNAs anticipated risks and adjusted the plan accordingly; this result is comparable to the findings of other studies of surgical teams in the OR [ 35 , 36 ], and confirms the OR as a CAS [ 7 ]. In our study, the surgeons said that usually they knew the patient, but when this was not the case they planned for the patient’s care by reading the record and created a mental model. Similarly, to our results, planning [ 35 ] coordination, behavior and adaptive coordination strategies [ 19 ] have been previously described as important strategies for surgical teams to manage their tasks. The preoperative plan also showed to serve as a shared mental model for the team [ 19 , 32 ] which allowed new situations to be contrasted and evaluated. In general, shared mental models have been described related to positive outcomes by creating effective teamwork [ 33 ] and minimizing preventable uncertain processes and performance [ 42 , 43 ] in ad-hoc constellations of teams [ 42 ]. On an individual level, mental models can also limit professionals by using familiar ways of thinking and acting. Professionals are usually not aware of these models or potential effects on their behavior [ 44 ]. When working in a CAS it can be difficult to get a sense of the whole solely from detailed descriptions such as guidelines. Sensemaking and mental models seems to have the ability to enhance planning for the expected and unexpected. However, in a dynamic CAS such as the OR, mental models need to be shared and discussed within the team [ 19 , 42 ] to avoid misunderstandings.

To be able to adapt to the unexpected, the three professional groups were unanimous in stating that prioritizing and solving upcoming problems was necessary in order to handle the unexpected. From a theoretical perspective when an unexpected event occurs, first it must be noticed, then the surgical team has to make sense of it, and then they have to do something about it [ 45 ]. To be able to adapt to unexpected events, the ORNs and RNAs described that they used previously created plans B and C, which were a part of the mental model when planning and preparing for the procedure. These results are similar to the findings of other studies in the OR context [ 19 , 35 , 36 ]. Having several plans appears to be a common key strategy to handle unexpected events in a CAS. However, the present study also shows the necessity of the planning phase being done carefully, as this appears to be a pre-requisite for a reflexive and quick response when unexpected events occur. From the perspective of resilience, adaptation is a central key factor that is not always about changing the plan, model, or previous approaches, but sometimes involves the readiness to modify plans to suit changing situations. Woods [ 46 ], describes this ability as being able to recognize and to stretch, extend, or change what is being done or had been planned to be done. In our study, prioritizing and solving upcoming issues was a crucial strategy as the problem had to be solved; inaction was not an option. The same strategies were also expressed in other OR studies; in order to respond to unexpected events, adaptability [ 33 ] and adaptive coordination were identified as important for safe performance, and were usually achieved through communication [ 19 , 31 , 32 ].

Patient safety and risk arise through variability and the managements’ ability to provide resources and pre-conditions with different degrees of freedom on which the adaptations from the surgical team are based. However, there is a need for reflection on the extent of the ability to adapt and the degrees of freedom needed in the adaptation. Resilience is often expressed as the extensibility of the system, which may result in pushing the limits for taking risks too far; this is intimately linked to exposure to risk. However, the risk of high adaptive capacity is that adaptations become normalized and signals of organizational weaknesses are masked by individual’s ability to adapt and therefore, despite system deficiencies, more difficult to be perceived by decision makers [ 47 ], balanced considerations must be considered.

Methodological considerations

One strength of this study is the inclusion of three OR core professional groups with varied gender, age, and experience. However, the mean age and experience were both quite high, probably due to that the included OR department had quite low turnover rates among staff. This can be considered as both a strength and a limitation. On one hand, individuals with a lot of experience may contribute with more rich descriptions than those with less experience. On the other hand, perceptions from less experienced could have contributed with more variations in the phenomena of study. Transferability of qualitative results is difficult, as these results are highly dependent on the studied context. To ensure trustworthiness [ 48 ] in terms of confirmability, we have presented a selection of transcripts, codes, sub-categories, and generic categories in Table 2 . To increase the credibility, interactive discussions of codes, sub-categories and generic categories took place among the authors, and quotations are presented in connection to the descriptions. Further, triangulation of sources was made of similar descriptions of the same phenomenon by the three professionals, and analyst triangulation was achieved by the research group through independent categorization. To ensure dependability, open questions were asked using an interview guide during all group interviews. The aim for choosing group interviews, instead of individual interviews was to obtain each professional group’s perceptions and experiences by dynamic group interactions. Since the OR is an unpredictable context, there was uncertainty in how many participants that could attend the planned time and day for the group interviews. The interviews were conducted at two central OR departments at one county hospital and one local county hospital in mid-Sweden by reasons as practical feasibility to obtain access to professional groups. The interviewer was an RNA, which may have affected the interpretation of the results both positively, by making it easier to interpret context-specific nuances, and negatively, by taking things for granted. As described previously, surgical teams in Sweden usually consist of six different professionals. The focus in this study was on the core professionals of the OR, including ORNs, RNAs, and surgeons. This may be considered a limitation, as not all professionals were represented.

Creating safe care in the OR should be understood as a process of anticipating, planning, and preparing in order to manage challenging and complex work processes. OR staff need preconditions and resources such as having experience and coordinating and reaffirming information, to make sense of different situations. This requires a mental model, which is created through planning and preparing in different ways. Some situations are repetitive and easier to plan for but planning for the unexpected requires anticipation from experience and coordination among team members. The main results strengthen that the four abilities in the theory of resilience is used by OR staff as a strategy to manage complexity in the OR. Managing complexity seems dependent on clinical experience. Therefore, future research should focus on how to provide effective learning of effective strategies for safe practice in a complex health care environment for less experienced colleagues.

Clinical implications

Managing complexity in the OR, being able to respond to the expected and unexpected, requires adaptive capacities such as anticipating and monitoring. Before a procedure starts surgical teams should use safety briefings to discuss potential challenges and risks and solve problems. To promote learning and to have the same goals, mental models should be shared and discussed between team members. After the surgical procedure, debriefings about what and why things went right or wrong and what could be improved may support reflective learning [ 34 ].

Availability of data and materials

Data are available on request for any interested researchers to allow replication of results provided all ethical and legal requirements are met according to GDPR, The General Data Protection Regulation for the European Union. Contact person, Center for Clinical Research, Dalarna, Uppsala University ( [email protected] ), Nissers väg 3, SE-79182 Falun, Sweden.

Abbreviations

Complex adaptive system

• Operating room

Operating room nurses

Registered nurse anesthetists

Resilience engineering

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Acknowledgements

We also thank the heads of the participating departments and the surgical teams for their willingness to participate in this study.

The Center for Clinical Research Dalarna and the Department of Anesthesia and Intensive Care Unit Falu Lasarett supported this work but was not involved in the design and running of the study. Open access funding provided by Dalarna University.

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Camilla Göras & Anna Ehrenberg

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Camilla Göras

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Ulrica Nilsson & Maria Unbeck

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Ulrica Nilsson

Department of Health and Caring Sciences, Linnaeus University, Kalmar/Växjö, Sweden

Mirjam Ekstedt

Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden

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CG, UN, ME, MU and AE contributed to the study design. CG was the project supervisor and performed the group interviews together with AE. CG also undertook the initial interpretation of the data, which was followed by discussions with UN, ME, MU and AE. Drafts of the manuscript were reviewed by UN, ME, MU and AE. All authors have read and approved the final manuscript.

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Correspondence to Camilla Göras .

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This study was conducted according to International research ethics and standards following the Declaration of Helsinki and was approved by the Swedish Ethical Review Authority in Uppsala, Sweden (No. 2016/264). To get permission to conduct the study, information was provided both verbally and in writing to the medical director of the surgical department and nurse managers at the OR department. Those who volunteered gave their written informed consent after receiving verbal and written information from one researcher (CG) including the voluntary nature of participation and the ability to withdraw at any time without further explanation, and confidential treatment of data. The manuscript had followed the reporting criteria for qualitative research according to the COREQ checklist.

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Göras, C., Nilsson, U., Ekstedt, M. et al. Managing complexity in the operating room: a group interview study. BMC Health Serv Res 20 , 440 (2020). https://doi.org/10.1186/s12913-020-05192-8

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A Peek Inside the Operating Room: Eight Insights From a Circulating Nurse

When you think of the operating room (OR), what comes to mind? An intense and stressful work environment? A place where you have to think and act quickly? It’s certainly all of those, and more. I spent more than 40 years working in nursing before joining 3M five years ago. For most of that time I worked in the perioperative area and I can tell you that, yes, sometimes the OR is an intense, emotionally charged place. It is also a place where teams work together with a singular focus on the patient, making it a highly rewarding environment.

I knew from my experience during clinicals that I wanted to work in the OR. At my first hospital, I visited the nursing director regularly to see if there were any openings. After about six months, I got my chance. I first learned how to scrub – setting up the instruments and handing them to the surgeon during the procedure – and then I moved into circulating, a more typical RN role of providing direct patient care before, during and after the procedure.

Curious about what it’s like? Here are a few insights from my experience:

1. your number one job is to be the patient’s advocate..

When a patient is in surgery, they need an advocate as they are unable to advocate for themselves. Some people may view the role of an OR nurse as more clinical and less caring, but I found it very patient focused. I would meet with patients before surgery to both reassure them and assess their readiness for the surgery, telling them, “I’ll be there when you fall asleep and I’ll be there until you are out of surgery.”

2. The job responsibilities can vary.

Most ORs will have nurses who perform two different functions: the more technical job of scrubbing – assisting the surgeon directly and handling instruments – and circulating. Circulating nurses’ responsibilities include:

• Knowing all the pertinent information about the patient and verifying that it’s the correct patient on the table going in for the scheduled procedure.
• Positioning the patient appropriately and properly prepping their skin for the incision.
• Managing the room, including supplies, equipment, lighting and documentation. The circulating nurse ensures there’s not a break in sterile technique. If patient status changes, you may have to switch what you are doing – stepping in to help anesthesia, for example.
• Initiating counts when it’s time to close – accounting for all sponges, blades and other instruments.

3. It took about a year to feel really comfortable in the role.

My orientation paired me with an experienced nurse for six months of scrubbing and six months of circulating, which helped me feel comfortable. Today, the orientation periods are usually shorter and nurses may have to adjust more quickly.

4. Every day may be different.

If you work at a specialty surgery center, your workday may be more predictable than if you work in a general surgery setting. Depending on the type of procedures you work on, one provider could do up to 20+ surgeries in one day. Eye surgery is an example of a surgery that may take less than 30 minutes. In this situation, you may be switching back and forth between two ORs all day. On the other hand, one complex surgery – such as a transplant or a reconstruction – can take the entire day and even extend beyond a normal shift.

Technology and increasing specialization also are changing work in the OR. Total joint replacements  used to be much more invasive procedures. Minimally invasive surgery has transformed how replacements are done, and some surgery centers focus entirely on these surgeries.

5. Every surgery is customized to the patient, but standards are always followed.

It’s important to follow protocols and standards to help ensure consistent patient care on outcomes. Every patient is different though, and care should be customized for each person depending on their scheduled procedure, skin condition, their body shape and their overall health status. It may mean you need to adjust positioning, make a different selection for skin preparation, or utilize different equipment to accommodate various needs.

6. A strong, but respectful, personality is helpful.

When you work in the OR, you are always advocating for the patient, so you need to speak up. You have to bring concerns forward in a clear, but respectful, way. Attention to detail and critical thinking skills are also crucial.

7. The hardest part of the job is the stress.

Emotions can run high in the OR. If you are working on a cardiac case, a trauma case or a ruptured aneurysm, everyone is highly focused on reaching the critical point in the surgery. You may also have irregular hours and be on-call for emergencies.

8. The best part of the job is the teamwork.

There is nothing as satisfying as working with a good team. If your team is aligned, you will probably know what the surgeon or scrub tech needs before they do. You are all focused on one patient at a time and are working together to provide excellent care for them.

I loved my years working as a nurse. While my roles varied – from staff nurse to nurse manager and clinical director and from setting up a brand-new surgery center to a pain management center – in each case, my focus has been on the patient.  If you are compassionate, want to be an advocate for your patients, love being part of a team, and don’t mind a high-stress environment, being an OR nurse might be a great fit for you, too.

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• Open access
• Published: 10 April 2024

Surgical counting interruptions in operating rooms

• Zhi Lujun 1 ,
• Gao Yuan 2 &
• Wang Wei 2  

BMC Nursing volume  23 , Article number:  241 ( 2024 ) Cite this article

238 Accesses

Metrics details

Operating rooms are complex working environments with high workloads and high levels of cognitive demand. The first surgical count which occurs during the chaotic preoperative stage and is considered a critical phase, is a routine task in ORs. Interruptions often occur during the first surgical count; however, little is known about the first surgical counting interruptions. This study aimed to observe and analyse the sources, outcomes, frequency of the first surgical counting interruptions and responses to interruptions.

A retrospective observational study was carried out to examine the occurrence of the first surgical counting interruptions between 1st August 2023 and 30th September 2023. The data were collected using the “Surgical Counting Interruption Event Form”, which was developed by the researchers specifically for this study.

A total of 66 circulating nurses (CNs) and scrub nurses (SNs) were observed across 1015 surgeries, with 4927.8 min of surgical count. The mean duration of the first surgical count was 4.85 min, with a range of 1.03 min to 9.51 min. In addition, 697 interruptions were identified, with full-term interruptions occurring an average of 8.7 times per hour. The most frequent source of interruption during the first surgical counts was instruments ( N  = 144, 20.7%). The first surgical counting interruptions mostly affected the CN (336 times; 48.2%), followed by the ORNs (including CNs and SNs) (243 times; 34.9%) and the SN (118 times; 16.9%). Most of the outcomes of interruptions were negative, and the majority of the nurses responded immediately to interruptions.

Conclusions

The frequency of the first surgical counting interruption is high. Managers should develop interventions for interruptions based on different surgical specialties and different nursing roles.

Peer Review reports

Introduction

The operating room is characterized by high workloads, advanced technology, and the involvement of multiple and interdependent medical specialties. Furthermore, operating rooms are error-prone environments. Therefore, the Association of Operating Room Nurses (AORN) recommends that nurses implement no interruption zones in the perioperative environment when performing processes in critical phases that require concentration to avoid distractions and errors [ 1 ]. Surgical counting is an important procedure for ensuring the safety of patients and the occupational health of medical staff. Therefore, surgical counting is a critical phase.

According to the guidelines proposed by the Chinese Nursing Association (CNA) and AORN, the standard surgical count procedure requires at least four counts, as follows: first, before the start of the surgery; second, before closing the body cavity; third, after closing the body cavity; fourth, after surgery. The first surgical count is the most critical phase and is the basis for the subsequent three counts. It occurs during the busy and chaotic preoperative stage, and OR nurses are responsible for providing high-quality perioperative care and supporting anaesthetic-surgical interventions by providing necessary supplies and surgical equipment and monitors, as requested by the OR team. Therefore, interruptions often occur.

Interruption refers to a reaction triggered by external stimuli or secondary activities that interrupt focused concentration on a primary task, thus leading to task switching or concurrent multitasking [ 2 , 3 ]. The definition includes the source, attributes, outcomes and responses. The attributes of interruptions are classified as intrusions, distractions, discrepancies, and breaks [ 3 ]. The outcomes of interruptions can be either positive or negative. The responses to interruptions are classified as immediate interruptions, slightly delayed, multitasking and refused interruptions. Currently, most related studies have examined the negative aspects of interruptions [ 4 , 5 ]. Surgical counting interruptions may result in prolonged operating time, reduced risk detection capabilities, and increased mental workload [ 6 , 7 , 8 ]. Therefore, measures should be taken to respond to interruptions, which should be managed according to source, attributes, outcomes and responses.

Through a literature search, we found that current interruption studies have focused mainly on interruptions in the ICU and in the ward [ 4 , 9 ]. Few studies have focused on interruptions in the OR, and these studies have focused on interruptions during the entire surgical procedure. Fewer studies have focused on surgical count. We therefore observed and analyse the sources, attributes, outcomes of the first surgical counting interruptions and responses to interruptions with the aim of investigating the frequency of the first counting interruptions and frequency of circulating nurses and scrub nurses affected by interruptions.

This study was approved by the ethics committee of the study hospital (West China Hospital of Sichuan University (No. 209)). This was a retrospective observational study. The study observed and analysed the sources, attributes, outcomes and frequency of the first surgical counting interruptions and responses to interruptions by reviewing surveillance video recordings of ORs at West China Hospital, Sichuan University, which is a national treatment centre for severe and complicated cases in Southwest China, from 1st August 2023 to 30th September 2023. The study included OR teams from four surgical specialties, namely, cardiovascular surgery, thoracic surgery, neurosurgery, and plastic surgery. Emergency surgery was excluded because of the relative flexibility of staffing. Study participants were selected from a total of 147 nurses by simple random sampling. This data consisted of 1,203 patients, of which 188 were excluded due to unclear or incomplete surveillance videos or data from procedures performed under local anaesthesia. As a result, 1,015 surgeries were included in the data analysis.

The observed preoperative stage for each patient included the time from the start of the first surgical count to its end; moreover, any discrepancy was checked after all counts were complete and surgery was over. The hours of observation per day were 8 h. Before the survey, we reviewed domestic and foreign literature and then designed a surgical counting interruption event form. Then, experts were consulted to test the content validity and develop a revised version of the form. Six experts assessed the relevance of the items in the first draft of the table and suggested revisions. We calculated the item content validity index of the form (i.e., 0.83–1) and the content validity index of the complete observation form (i.e., 0.83). The revised version of the form was used to test surveillance video recordings for 20 surgeries (i.e., 102.21 min), after which the final version of the observation form was developed. Cronbach’s α coefficient of the complete observation form was 0.71. The observation form included general information such as participants’ demographics (gender, age, education, and years of working experience), the first surgical count duration, and attributes, outcomes of the first surgical counting interruptions and responses to interruptions. The sources of interruption were classified as follows:

people entering or exiting the OR (e.g., borrowing or returning something, requesting help);

surgeons (e.g., informing CNs to prepare the special surgical instruments or other supplies);

anaesthetists (e.g., asking CNs to intervene when the intravenous injection is too slow, asking CNs about the order of surgical medication, asking CNs for supplies);

instruments (difficulty in checking the integrity of microsurgical instruments, e.g., tips of microsurgical scissors, the small assembly screws which are built-in);

disinfection supply centre (e.g., not closing the tip of the clamp neatly, order of instrument string does not match instrument count paper);

procedure (interruptions intrinsic to surgical work, e.g., ring forceps and other materials are required for sterilization of surgical sites during the first surgical count).

environment (e.g., the ringing of the fixed-line telephone in the OR, noises from equipment alarms, messy operation tables, overly loud music, noise outside the OR);

electrophysiological monitoring staff (e.g., requesting to record number of electrodes).

nurses themselves (e.g., surgical count was too fast, CNs asked to check again, discrepancies between surgical count and instrument count paper, teaching SNs at the start of the learning curve).

Prior to the formal observation, the researcher selected and trained two observers. The criteria of the observers were as follows: (1) had a registered nurse with > 5 years of working experience in OR, (2) were familiar with the surgical specialties involved in this study, and (3) did not participate in the operation during the observational period. The observers were trained on the requirements for surveillance video data and the concept of interruption, and they correctly interpreted the content of each observation index and key component in the observation. To ensure the objectivity and accuracy of the collected data, two observers simultaneously reviewed surgical surveillance video for 20 surgeries using the “Surgical Counting Interruption Form”. Any disagreements were resolved by discussion to ensure consistency. Interrater reliability was calculated between the two observers, with a kappa coefficient of 0.81.

Data analysis

Statistical analysis was conducted using SPSS 22.0 software. To ensure data accuracy and integrity, the original data were entered and checked by two researchers. The frequency and constituent ratio were used for statistical description, chi-square tests were used for the comparison of categorical data, and analysis of variance (ANOVA) was used for the comparison of continuous variables. P  < 0.05 was considered to indicate statistical significance.

Participants’ demographics

Among 66 circulating nurses (CNs) and scrub nurses (SNs), 60 (90.9%) were female, and 6 (9.1%) were male, 62 (93.9%) were bachelor’s degree or below, and 4 (6.1%) were graduates, 0–5 years of clinical practice were 9 (13.6%), 5–10 years of clinical practice were 45 (68.2%), and > 10 years of clinical practice were 12 (18.2%) (Table  1 ).

1015 surgical counts were performed within 82 h and 7.8 min. The mean surgical count duration from the start to the end of the first surgical count was 4.85 min, with a range of 1.03 min to 9.51 min. No discrepancies were found after all counts were complete and surgery was complete. The study included OR teams from four surgical specialties, namely, cardiovascular surgery ( N  = 232, 22.86%), thoracic surgery ( N  = 232,2 2.86%), neurosurgery surgery ( N  = 348, 34.28%) and plastic surgery ( N  = 203, 20.0%). A total of 697 interruptions were identified. This means that the full term was interrupted 8.7 times per hour on average. Table  2 presents the total counts and their interruption sources from 1015 surgical counts. Most of the observed interruptions were caused by instruments ( N  = 144,20.7%). The remaining interruptions were attributed to the procedure ( N  = 120, 17.2%) or to the disinfection supply centre ( N  = 117, 16.8%) (Table  2 ).

The first surgical counting interruptions affected CNs 336 times (48.2%), ORNs (including CNs and SNs) 243 times (34.9%) and SNs 118 times (16.9%). The overall distributions of the first surgical counting interruption sources were significantly different among CNs, SNs and ORNs (including CNs and SNs) (X 2  = 154.515, P  < 0.001) (Table  3 ).

The results of multiple comparisons were significantly different. Compared with SNs and ORNs (including CNs and SNs), CNs were more affected by the first surgical counting interruptions (X 2  = 77.618, P  < 0.001; X 2  = 12.775, P  < 0.001) (Table  4 ).

In total, the study identified 697 interruption-associated 628 negative outcomes (90.1%) and 69 positive outcomes (9.9%) (Table  5 ). The overall distributions of interruption attributes included intrusions ( N  = 421, 60.4%), distractions ( N  = 127, 18.2%), discrepancies ( N  = 26, 3.7%), and breaks ( N  = 123, 17.7%) (Table  6 ). Intrusion was the major type of the first surgical counting interruption. We classified the responses to the first surgical counting interruptions into immediate interruptions ( N  = 446, 64.0%), slightly delayed interruptions ( N  = 113, 16.2%), refused interruptions ( N  = 33, 4.7%), and multitasking ( N  = 105, 15.1%) in this study (Table  7 ).

In this study, 697 surgical counting interruptions were recorded from 1015 surgical counts, with an average of 8.7 interruptions per hour. It has been previously reported that the frequency of interruptions was an average of 3–9.62 times per hour [ 10 , 11 ]. However, this study revealed a greater level of interruptions. Surgical counting interruptions may prolong the process of surgical count. Because of time constraints, ORNs(including CNs and SNs) were rushed during surgical count. Human error may occur in manual count systems. It is dangerous for the patient and the surgical team. High-frequency interruptions may also increase stress, which may result in inferior technical performance [ 12 , 13 ]. Therefore, these interruptions may affect the ability to identify hazards during surgery. Cognitive load theory views working memory as the primary bottleneck for learning, as it is limited in both retention and capacity [ 14 ]. Surgical count requires high working memory demands; therefore, interruption during surgical count may affect memory recall. Moreover, the first surgical examination is the initial phase of the procedure. Interruptions that accumulate over time reduce the compensatory resources of the ORNs (including the CNs and SNs), which may also affect the next procedure and safety of patients [ 15 ].

The observation data revealed that the main source of the first surgical counting interruptions was related to instruments (20.7%), followed by procedures (17.2%) and disinfection supply centres (16.8%). It should be noted that this finding may differ from other studies that suggested that the main sources of interruptions were entering/exiting the OR and communications [ 16 , 17 ]. The difference may be related to different study phases and/or samples. Notably, we only investigated the first surgical count, while other studies have investigated the whole procedure. Interruptions induced by instruments have been rarely reported. We discovered that the factors related to checking the integrity of microsurgical instruments were the primary source of the first surgical counting interruptions. The development of microsurgical instruments parallels the growth of microsurgery, and microsurgical instruments will also be improved in accordance with doctors’ needs; both of these improvements will result in greater complexity in the design and use of such tools [ 18 ]. The microsurgical instruments that cause distress are the small assembly built-in screws and delicate tips. It is difficult and time-consuming to check the integrity of these materials. Surgical count may be performed under time pressure and safety pressure.

The study analysed the effects of the first surgical counting interruption on CNs, SNs and ORNs (including CNs and SNs) using observational data, and different nursing roles may be affected by differences in the sources of interruption. CNs were significantly more affected by the first surgical counting interruptions than SNs and ORNs (including CNs and SNs), which is consistent with prior research [ 15 ]. CNs and SNs are involved in surgical count, and the CN is usually an experienced nurse who plays an important role in surgical count. Some strategies, such as the implementation of safe zones, the Stay S.A.F.E. strategy are used to reduce interruptions [ 1 , 19 ]. However, CNs cope with interruptions of the OR, surgical team and patient, and the nursing work environment is complex [ 20 ]. Therefore, there is no way to eliminate all interruptions in ORs. Surgical counting is often performed with a shortage of personnel, as it is a routine task that does not require increasing the number of team members [ 21 ]. Administrators should carefully consider optimizing staffing during chaotic stages and critical phases.

The results also showed that the majority of nurses who responded to the first surgical counting interruption immediately stopped their work. There may be three reasons for this. First, nurses regard interruption as an integrated part of clinical care. they are used to being interrupted at any time and in any situation. Therefore, they do not consider doing something to avoid it. Second, surgery is multidisciplinary. They had to take breaks immediately to coordinate with other team members. Third, the interruption may be positively related to the safety of the patient. Surgical count requires concentration, and interruptions may lead to distraction and influence the discovery of security threats [ 6 , 22 ]. Managers should improve systems and processes to reduce unnecessary interruptions. Meanwhile, targeted strategies, such as training nurses to distinguish between detrimental and beneficial interruptions as well as perfecting their ability to respond to interruptions, may be effective [ 23 , 24 ].We also found that multitasking was performed. Multitasking increases stress [ 25 ], thereby affecting the identification of surgical count hazards. Multitasking may be expressed as an integral part of daily practice and is inevitable, but it is important to create an environment where nurses can focus on critical phases to improve patient safety [ 26 , 27 ].

In conclusion, the frequency of the first surgical counting interruption is risky, and managers need to take steps to improve it. Although all counts were completed, no discrepancy was found at the end of the surgery. This may be within the range of resilient coping of ORNs (including CNs and SNs). The frequency of interruptions varies among surgical specialties and nursing roles (CNs and SNs), and the sources of interruptions also differ. Managers should consider the unique needs of each surgical specialty and nursing role (CNs vs. SNs) when developing interventions. Considering the supportive attributes of CNs and the complex working environment in ORs, interventions need to consider the support of systems and process improvements.

Limitations

This study has several limitations. First, this study collected data through an observer’s review of surveillance video recordings, which may have resulted in some data loss due to human limitations such as attention span, distraction and memory of events. Second, our observations were limited to four disciplines of one hospital; therefore, the results may not be applicable to other hospitals. It is necessary for future research to enrol participants from hospitals at different levels and from more disciplines to improve sample representativeness. Third, this was an observational study. Future longitudinal studies or intervention studies that focus on the development of targeted strategies and the evaluation of their effectiveness are needed.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to privacy and ethical restrictions but are available from the corresponding author on reasonable request.

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Acknowledgements

Authors would like to thank Yue Li, Doctor of West China School of Medicine at Sichuan University, for her statistical consultation.

This study is supported via funding from National Key Research and Development Program of China (No. 2022YFC3602203).

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Anesthesia&Operation Center, West China Hospital, Sichuan University, Chengdu, China

West China Hospital, Sichuan University, No. 37 Guoxue Xiang, Wuhou District, 610041, Chengdu, Sichuan, China

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Contributions

Zhi Lujun, conceived and designed the analysis, data analysis, writing design, results and gathering the primary manuscript. Zhi Lujun and Gao Yuan, data collection and reviewing the primary manuscript, Zhi Lujun writing discussion. Zhi Lujun and Wang Wei, final reviewing the manuscript and consultation for study design. All authors reviewed the manuscript.

Corresponding author

Correspondence to Wang Wei .

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The research was performed in accordance with the Declaration of Helsinki. The ethical approval for the study was approved by the ethics committee of the study hospital (West China hospital of Sichuan University (No. 209)).This is a non-interventional and observational study that collected data through surveillance video recordings of the ORs. The data are used solely to guide clinical practice. The participants were aware of the presence of surveillance cameras, and their names were coded, the need for informed consent to participate was waived by the ethics committee of the study hospital (West China hospital of Sichuan University).

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Lujun, Z., Yuan, G. & Wei, W. Surgical counting interruptions in operating rooms. BMC Nurs 23 , 241 (2024). https://doi.org/10.1186/s12912-024-01912-1

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1.6: The Operating Room Environment

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The operating room (OR) is a sterile, organized environment. As a health care provider, you may be required to enter the OR during a surgical procedure or to set up before a surgical procedure. It is important to understand how to enter an OR area and how the OR area functions to maintain an sterile environment.

Members of the surgical team work hard to coordinate their efforts to ensure the safety and care of their patients. The surgical team is in charge of the OR and makes decisions regarding patient care procedures. The OR environment has sterile and non-sterile areas, as well as sterile and non-sterile personnel. It is important to know who is sterile and who not, and which areas in the OR are sterile or non-sterile.

Sterile OR Personnel

• Surgical assistant
• Scrub nurse

Non-sterile OR Personnel

• Anesthesiologist
• Circulating nurse
• Technologist, student, or observer

There are specific requirements for all health care professionals entering the OR to minimize the spread of microorganisms and maintain sterility of the OR environment. Prior to entering the OR, show your hospital-issued ID and inform the person in charge of the purpose of your visit. Refer to Checklist 10 for the specific steps to take before entering an OR.

Critical Thinking Exercises

• Why should the sterile field always be kept in sight by the scrub nurse or circulating nurse?
• Name three health care providers who are considered sterile in the OR area.

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• v.28(1); 2023
• PMC10064827

Emotions and team communication in the operating room: a scoping review

Henrietta lee.

a Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Grafton,Auckland 1023, New Zealand

Robyn Woodward-Kron

c Department of Medical Education, Melbourne Medical School, The University of Melbourne, Parkville, VIC 3010, Australia

b Department of Anaesthesiology, School of Medicine, The University of Auckland, Grafton, Auckland 1023, New Zealand

d Honorary Consultant, Department of Anaesthesia and Perioperative Care, Auckland City Hospital, Park Rd, Grafton, Auckland 1023, New Zealand

Jennifer Weller

Training in healthcare team communication has largely focused on strategies to improve information transfer with less focus on interpersonal dynamics and emotional aspects of communication. The Operating Room (OR) may be one of the most emotionally charged hospital environments, and is one requiring excellent team communications. We aimed to identify literature reporting on the emotional aspects of OR team communication. Our research questions were: what are the triggers in the environment that provoke an emotional response affecting communication, and what are the emotional responses to communication between OR team members; and how do these emotional aspects of communication affect the function of the OR team? We undertook a Scoping Review of literature across relevant databases following published guidelines, and narrative synthesis of the identified studies. From the 10 included studies we identified three themes: (1) Emotional experiences in the OR and their contributors; (2) Effects of emotional experiences on team communication; and (3) Solutions to manage the emotional experiences in the OR. Theme 1 sub-themes were: (1) Range of emotions experienced in the OR; (2) Hierarchical culture and (3) Leadership expectations as contributors to negative emotions. The OR is an emotionally charged environment. The hierarchical culture can inhibit staff from speaking up, and failure of leaders to meet team expectations, e.g., through appropriate and timely communication, may cause frustration and stress. The consequences of emotions include poor team dynamics, ineffective communication and potential negative impact on patient care. Few studies described strategies to manage emotions in the OR. The studies reviewed describe an environment where emotions can run high, affecting interpersonal communications, team function and patient care. The few identified studies relevant to our research questions demonstrate a need to better understand the emotional aspects of OR team communication and the effectiveness of interventions to improve these.

Introduction

Effective communication among multidisciplinary health professionals in a surgical team is necessary to deliver high-quality care to patients and minimise patient harm [ 1 , 2 ]. Many researchers have designed interventions to improve team communication in the operating room (OR), such as briefing [ 3 , 4 ]; closed-loop communication [ 5 , 6 ] and techniques to encourage junior staff to speak up [ 7 , 8 ]. While these interventions may not have been widely adopted in the workplace [ 9–11 ], there is evidence that, when used in the OR, they may lead to: improved perception of team communication [ 3 ]; improved transfer of information [ 4 , 5 ]; increased quality of communication [ 12 ]; more structured communications for handover of patient information [ 4 , 5 , 13–15 ]; and improved ability to speak up with concerns [ 8 ].

However, communication is more than an act of transfer of information, and clinical educators have perhaps spent less time on the interpersonal dimensions of communication. For example, stress, anxiety or frustration may influence how a clinician communicates, and how that communication is perceived and responded to by others. A communication may invoke an emotional response in the receiver, or the team, such as distress, anxiety, or defensiveness. These emotional responses may be accompanied by a physiological response such as increased heart rate, sweating or tremor. Such responses may affect subsequent team interactions, and ensuing team function and may potentially impact on patient care.

According to the linguist Halliday [ 16 ], the interpersonal function of language expresses the role of each speaker in an interaction, including interpersonal dynamics between speakers and emotional cues. The choice of words and phrases used in an interaction between speakers will likely reflect the context of the communication, including the interpersonal dynamics of the speakers involved: for example, a surgeon calling an anaesthetist ‘Anaesthesia’ rather than by name may be a hierarchical dynamic which suggests that the leader doesn’t need to know the names of their team members. Extensive use of imperatives when making requests, for example, ‘get the next patient,’ may negatively affect the interactional dynamics whereas more polite phrasing, such as ‘are we ready to fetch the next patient?’, ‘please could you’, ‘would you mind’, ‘thank you’ may have a more positive impact. The speaker’s intonation may also have an impact [ 16 ].

In the context of hospital ORs, Lingard et al. [ 17 ] noted that non-verbal cues, tone of voice, or use of repetition and emphasis can indicate signs of tension [ 17 ]. When surgical team members are under stress, their communication patterns may change and this has implications for other team members, including both their actions and their sense of well-being. In another study, anaesthetists rated communication with surgeons and other hospital staff as one of the greatest occupational stressors [ 18 ]. Stress may trigger negative emotions, and both stress and negative emotions have detrimental effects on team communication, job satisfaction and well-being [ 18 ]. In an interview study of senior OR staff, participants described how a team member raising concerns about their actions could provoke a negative and unhelpful response, which in turn could affect the rest of the healthcare team, potentially limiting effectiveness of patient care [ 19 ].

Thus it seems that emotions experienced by health professionals in the OR work environment are important, and may affect the quality of team communication, team performance and team-member well-being [ 20 ] and potentially impacting on the effectiveness of team-building, interprofessional communication and patient care.

The purpose of this scoping review was to identify and synthesise the current state of knowledge regarding the emotional aspects of team communication in the complex and fast-moving OR environment. For the purpose of this review, we used the MerriamWebster’s definition of emotion as: ‘A conscious mental reaction (such as anger or fear) subjectively experienced as strong feeling usually directed toward a specific object and typically accompanied by physiological and behavioural changes in the body.’ (URL: https://www.merriam-webster.com/dictionary/emotions ). We adapted this definition to the context of team communication and defined the emotional aspects of communication as: the conscious mental reaction subjectively experienced as strong feeling that may influence how one person communicates to another, or responds to another’s communication. We included in this emotional response both verbal and non-verbal behaviours (e.g., shouting or stomping around the room).

The specific research questions for our scoping review were:

• What are the triggers in the environment that provoke an emotional response affecting communication, and what are the emotional responses to communication between the health professionals who work in the OR?
• How do these emotional aspects of communication affect the function of the OR team?

Materials and methods

We undertook a scoping review [ 21 ] and narrative synthesis of the literature to examine the current state of knowledge regarding the emotional aspects of team communication in the context of the OR. This review method was chosen because of the exploratory nature of the review and the inclusion of studies with heterogeneous designs and methodology. This review was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist guidelines [ 22 ]. The term team communication refers to all verbal and non-verbal exchanges between all members of the healthcare team in the OR treating the patient.

Search strategy

A keyword search was conducted on the following databases: PubMed, Medline (OVID), Embase, CINAHL. To define the search terms, we reviewed the Medical Subject Headings (MeSH) database and consulted a librarian at the Faculty of Medical and Health Sciences, University of Auckland. The following search terms were used: [emotions OR stress OR happiness OR anxiety OR frustration OR aggression OR well-being OR quality of life OR psychological safety] AND communication AND [operating room OR operating theatre OR surgery]. We included the above range of alternative terms to capture the literature relevant to different topics in the healthcare literature where emotions or emotional responses were potentially discussed. As we were seeking interpersonal communication in the OR team, we selected terms that referred to the OR environment rather than specific disciplinary groups. This search was conducted on 29 May 2019 and repeated on 18 September 2021 and included all literature up to the second week of September 2021. No limit was used on the start date of the search period.

Depending on the search requirements of each database, the search terms were modified to take into account alternative spellings (e.g., theatre, theater), synonyms or variations of the same search term (e.g., operating room, operating theatre), or truncated to include different suffixes attached to the same word root (e.g., surgeries, surgery, surgical). Phrases such as ‘quality of life’ or ‘well being’ or ‘psychological safety’, both with and without hyphen variations, were searched together as exact phrases. For all databases, the filters or limits used in the searches were human participants and article published in the English language. To maximise inclusion of articles relevant to the review, all types of studies (e.g., qualitative, quantitative, mixed methods, reviews, editorials) were included in the review.

Inclusion and Exclusion Criteria

An article was included if:

The research reported the direct emotions of participants in the context of communication between two or more health professionals within the hospital OR environment. Specifically, the article’s results and findings needed to include either (1) direct reports of participants’ feelings or (2) reports of verbal or non-verbal behaviour suggesting an emotional response (e.g. barking commands, stomping around the room).

An article was excluded if:

• It only reported inferences from contexts where participants reported what they thought the emotional state of other team members was.
• Emotional components or team communication (or both) were not the primary focus of the article, or the setting was outside of the OR or the main focus was provider-patient communication.

Selection Process

The initial list of article abstracts was screened by one researcher (H.L.) and categorised into ‘include’, ‘unsure’ or ‘exclude’ using the selection criteria outlined above. Next, H.L. assigned each abstract a number, and, using a random number generator, randomly selected 5% of abstracts (102 of 2,047 abstracts). These were divided into three sets of 34, each to be checked by one of the other researchers (J.W., R.W-K. or A.M.) by independently determining the inclusion or exclusion status of the articles. The authors agreed on the selection status of 97% (99 out of 102) of the abstracts. With the abstracts categorised as ‘unsure’, the authors reached consensus through discussion and through reading the full article where necessary. We searched the reference lists of included articles and those initially classified as ‘unsure’ for potentially relevant articles.

Information was extracted from the included articles and entered into two spreadsheets, one for qualitative studies, and one for quantitative and mixed method studies (see Tables 1 and 2 ). The Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) framework [ 23 ] was used for qualitative studies and the Population, Intervention, Comparison, Outcome, Time (PICOR) framework [ 24 ] for quantitative and mixed methods studies.

Summary of quantitative studies included in the review.

Summary of Qualitative Studies included in the Review.

We used the Mixed Methods Appraisal Tool (MMAT) [ 25 ] to assess the methodological quality of each of the empirical studies included in the review. The MMAT has a set of guidelines for each type of study (i.e., qualitative, quantitative RCT, quantitative non-randomised, quantitative descriptive, and mixed methods). Each set of guidelines has four criteria for determining how well the study was conducted to answer the research question. For example, one of the criteria for a qualitative study would be: was appropriate consideration given to how the findings relate to the context? And for a quantitative RCT: was there a clear description of the randomisation process? The total score ranged from zero to four, where a higher score represents higher quality.

A narrative synthesis of the included articles was conducted following the guidelines described in Popay et al. (2006) [ 26 ], where the data from included articles was explored, and patterns and relationships sought between the different studies.

The analysis was led by H.L. with input from the full research team at monthly intervals, and through email circulation of each component of article selection, article appraisal and analysis. The research team agreed on all aspects of the analysis and narrative synthesis, with disagreements resolved through discussion and review of the data.

A total of 10 articles met the inclusion criteria for the review. Figure 1 shows the PRISMA flow diagram of the search process. Of the 10 articles, eight were qualitative studies and two were quantitative studies. Of the eight qualitative studies, six were interview studies [ 27–32 ], one was a focus group study [ 33 ], one was an interview and focus group study [ 34 ]. Both of the quantitative studies were interventional studies: one used a pre-post design [ 35 ] and one was a randomised controlled trial [ 36 ]. All the included studies were of reasonable methodological quality, i.e., obtained an MMAT score of two or above. Therefore, all of the studies were included in the final review and discussed in the synthesis. The included studies are summarised in Tables 1 and 2 .

PRISMA flow diagram of the search process.

The included studies examined either the emotional triggers influencing communication or the emotional responses to communication in the surgical team. The studies could contribute to more than one of the identified three themes. These three themes were: (1) Emotional experiences in the OR and their contributors (10 studies); (2) Effects of emotional experiences on team communication (seven studies); and (3) Solutions to manage the emotional experiences in the OR (three studies). Studies could fall into more than one theme or sub-theme.

The first theme was the largest, and was divided into three sub-themes: The first sub-theme was range of emotions experienced in the OR (1a). The second sub-theme was hierarchical culture (1b) and how it contributed to the emotional experiences in the OR. The third sub-theme was leadership expectations (1c) and the emotional impact of perceived failings in the leader. Table 3 lists the studies included under each theme and sub-theme.

Studies included under each theme and sub-theme.

Theme 1: emotional experiences in the or and their contributors

1a. range of emotions experienced in the or.

Six studies identified the various types of emotions experienced by health professionals in the OR. In one study, Wetzel et al. [ 28 ] outlined the sources of stress in the OR, which included unexpected surgical complications, emergency cases, time pressure, equipment problems, and interpersonal issues between team members [ 28 ]. These stress-inducing events led to a range of emotions experienced by health professionals working in the OR. Surgeons often reported feeling anxious, angry, frustrated, irritated, a sense of urgency to think and act quickly and a tendency to rush when experiencing highly stressful situations in the OR [ 28 ]. In a simulation study by Armour et al. [ 27 ], anaesthetic nurses reported feeling vulnerable working in a team where members were unfamiliar with each other, and in an environment which was different to their usual workplace. Feelings of frustration and low self-confidence were commonly reported in the OR, when some team members were excluded from decision-making, overlooked and felt unable to speak up [ 27 ]. Team members also reported feeling scared, insecure, disrespected and frustrated when exposed to incivility or disruptive behaviour [ 30 , 31 ] or conflicts [ 32 ] in the OR. Nurok et al [ 35 ] devised a method to assess emotional climate in the OR, using observers’ ratings of the degree of tenseness and degree of engagement of health professionals in the OR and reported that the emotional climate of the OR was mostly engaged (e.g., staff alert, interested) and appropriately tense (e.g., staff’s level of anxiety was appropriate to context) [ 35 ]. Taken together, these studies suggested that the OR can be a highly stressful working environment. Health professionals reported feeling a range of negative emotions as a result of this stressful environment.

1b. Hierarchical culture

Six studies identified hierarchical culture as a major contributing factor towards these emotional experiences in the OR. A hierarchical culture was described where surgeons and senior doctors had power over trainees and other professionals (in particular, nurses). Studies have reported team members’ reluctance, difficulty and feelings of frustration experienced when speaking up to those at the top of the hierarchy [ 27 , 29 , 31 , 34 ]. Feelings of frustration and low self-confidence were also reported by nurses who were excluded from conversations between doctors [ 27 , 31 ]. Disruptive behaviours were another contributing factor towards negative emotional experiences in the OR. The disruptive behaviour identified in our included studies were unacceptable or inappropriate behaviour that could hinder teamwork, communication and psychological safety. A number of interview studies in our review reported the negative emotions experienced by health professionals that arose as a result of disruptive behaviour [ 27 , 29–31 , 33 ]. In an interview study by Higgins and MacIntosh [ 31 ], nurses were reportedly subjected to being the brunt of a surgeon’s bad mood and a ‘safe target’ to release the surgeon’s frustrations. Nurses also reported surgeons deliberately making the already anxious nurses feel uncomfortable by ‘stomping around the room’ [ 31 ]. Similarly, Chrouser et al. [ 30 ] reported that 98% of trainees had experienced surgeons’ disruptive behaviour in the OR, most commonly yelling, swearing, ‘barking’ commands, criticising, and throwing objects around. Trainees and nurses reported feeling scared and frustrated and concerned that the disruptive behaviour created tension in the room [ 30 ]. Despite this, some surgeons believed these behaviours were sometimes justified in order to quickly accomplish some task-related goals [ 33 ]. In the interview study by Chrouser et al. [ 30 ] above, trainees defended the surgeon’s disruptive behaviour and attributed it to stress and frustration.

1c. Leadership and expectations

Four studies pointed out how the emotional state of the leader and that of the team members can affect each other in team communication. Three out of four studies have suggested that the tone and attitude of the leader (most often the surgeon) set the mood in the OR and directly influenced communication effectiveness [ 28 , 34 ] and job performance in the OR [ 36 ]. In the study by Grade et al. [ 34 ], OR members felt more comfortable when the senior surgeon maintained a positive tone and attitude throughout the procedure [ 34 ]. In a simulation study by Katz et al. [ 36 ], anaesthesiology residents scored lower in all performance measures when working under a surgeon portrayed as ‘impatient’ compared to a ‘courteous’ surgeon [ 36 ]. The surgeons in the study by Wetzel et al. [ 28 ] reported that they had to make an effort not to show their own stress, in order to reduce tension among the surgical team members [ 28 ].

Leaders were also expected to communicate preferences, routines and information about the procedure to all team members. Skramm et al. [ 29 ] found that surgeons who did not clearly communicate their preferred instruments or suddenly wanted different instruments created stress, caused frustrations and poor communication among team members [ 29 ]. Similarly, Grade et al. [ 34 ] reported that when nurses and technicians were unable to tailor the equipment needs of the senior surgeon, communication ‘fell apart’. In addition, anaesthetists felt excluded and disengaged when the senior surgeon did not communicate to them the plans of the procedures and any updates during the procedure, which resulted in confusion and communication failures among team members [ 34 ].

Overall, these studies suggested that team members expect leaders of surgical teams to have good control of their own emotions, remain positive and clearly communicate their preferences and plans to all team members throughout the entire procedure. Negative emotions could arise if these expectations were not met.

To summarise Theme 1, the OR is an emotionally charged environment. The team expectations of the leader, coupled with the hierarchical culture of the OR, can create negative emotions and tension between team members which can compromise interpersonal dynamics as well as surgical team performance.

Theme 2: effects of emotional experiences on team communication

Seven studies reported the effects of negative emotional experiences on team communication in the OR. Within a hierarchical OR culture, the power difference between doctors and nurses influenced interpersonal communication, resulting in reluctance, difficulty and feelings of frustration when speaking up to those at the top of the hierarchy [ 27 , 29 , 31 , 34 ]. In an interview study by Skramm et al. [ 29 ], nurses reported that some surgeons dictate who may speak in the OR and who may not. Other surgeons reduced their communication to ‘barking’ commands and communicated their preferences at the last minute, which nurses found frustrating and daunting [ 29 ]. Some nurses indicated they were ‘prepared to accept unpleasant communication (from the surgeon) to maintain a good atmosphere in the OR’ [ 29 ] suggesting that incivility, and its consequences on team communication and function may go unchecked. After exposure to incivility, trainees were more reluctant to communicate with the surgeon [ 36 ] and nurses reported withdrawing communication and avoiding eye contact with the surgeon [ 31 ]. Similarly, other interview studies noted that health professionals involved in conflicts were more likely to avoid further interactions with each other [ 32 , 33 ].

Taken together, these studies in Theme 2 describe how a hierarchical culture can inhibit nurses and trainees from speaking up and voicing their concerns [ 27 , 29 , 31 ]. The OR team may be unclear about the plan for the procedure or needing an update on progress, but feel unable to seek clarification [ 34 ], compromising the ability of the team to prepare for anticipated events and respond to changes in the patient’s condition. Previous negative interactions can result in team members withdrawing from communicating or interacting with other members of the surgical team, potentially limiting their contribution to ensuring the safety of the patient.

Theme 3: Solutions to manage the emotional experiences in the OR

Three studies reported on participant suggestions or strategies for managing stressful situations in the OR. In the interview study by Wetzel et al [ 28 ], surgeons described coping strategies in stressful situations. These included (1) recognising the signs that they were stressed (e.g., heart pounding, clouded judgment); (2) stopping what they were doing and standing back; and (3) regaining control of self and the situation. With regard to regaining self-control, surgeons described techniques such as physical relaxation, distancing, self-talk, and trying not to show stress themselves in order to avoid creating stress in the team. To regain control over the situation, surgeons would pause to reassess the situation, make a decision, then plan and prepare for the next stage [ 28 ].

Two interview studies focused on how to manage conflicts provoked by stressful situations in the OR which could hinder effective communication. Rogers et al. [ 33 ] analysed conflicts in the OR and identified a set of behaviours that caused conflicts to progress or shift to negative consequences on communication and team dynamics. These behaviours included misattribution (e.g., blaming) and the use of harsh language (e.g., threats, insults, yelling, profanity). According to Rogers et al. [ 33 ], these behaviours could induce negative emotions and exacerbate conflict. Surgeons could potentially be educated on conflict management techniques such as how to constrain negative emotions and remain calm, and using alternative behaviours (e.g., apologising or other relationship rehabilitating behaviours) [ 33 ]. Dossett et al. [ 32 ] interviewed women surgeons who had been previously involved in conflicts with staff from a different discipline. They reported using strategies such as rapport building, relationship management techniques (e.g., gauging the emotional responses of others and recalibrating own actions based on those responses), and seeking out social support (e.g., talking about shared experiences with colleagues) to navigate the conflicts [ 32 ].

Overall, studies included in Theme 3 focused on senior doctors’ own awareness of stressors that can affect their performance and potential coping strategies, responses to stress or frustration that may escalate conflicts within the OR team and potential educational interventions to learn to better manage conflict.

In this scoping review we identified ten studies that reported on the emotional aspects of communication between health professionals working in the OR. These studies fell into three main themes: (1) Emotional experiences in the OR and their contributors; (2) Effects of emotional experiences on team communication; and (3) Solutions to manage the emotional experiences in the OR.

Our review highlights the emotionally charged environment in which OR teams work and the emotional responses to the traditional hierarchy. Failure of leaders to meet the team expectations of appropriate and timely communication may lead to team feelings of frustration and stress. The hierarchical culture can inhibit nurses and trainees from speaking up and voicing their concerns, or seek clarification of the plan, compromising the team’s ability to prepare and plan for the procedure. Team members may disengage from patient care as a result of previous negative interactions. Surgical views on managing this emotional undercurrent included managing their own stress and learning better conflict management skills.

Relation to broader literature

The included studies reported a variety of emotional triggers to communication in the OR such as feelings of anxiety, anger, irritation and frustration. Stressful events (e.g., unexpected surgical complications, time pressures, equipment and interpersonal issues) triggered these negative emotional experiences, which then reduced the quality of communication between team members and, as a result, triggered additional stress in the team members responding to the communication. This stress then led to negative emotional responses to the suboptimal communication, such as feeling disrespected, scared, insecure, frustrated. Thus, a vicious cycle was created of ineffective team communication. This finding is in line with other studies in the healthcare literature. For example, in the nursing literature, Thornby [ 37 ] explained that previous negative experiences in communication with a colleague created stress, anxiety and irritation in subsequent communication encounters, leading to ‘flight’ (e.g., becoming silent, ignoring) or ‘fight’ responses (e.g., sarcasm, angry responses), resulting in a continuing cycle of ineffective communication [ 37 ]. Ineffective communication can lead to delays and errors in patient care, which can compromise patient safety [ 20 , 38 ]. Our study, with its focus on the OR context, adds to the existing literature through exploring the subsequent impact on team communication in the OR when health professionals experience negative emotions during the course of their work. Incivility or disruptive behaviour is more likely to happen as a result of the high levels of stress that health professionals experienced, and stress is a feature of patient care in the OR environment. Incivility or disruptive behaviour and its damaging effect on interpersonal relationships have been reported in other acute care contexts [ 39–41 ] as well as the OR [ 42–44 ].

Conflicts and disagreements can arise more easily in stressful situations and this has adverse implications on team communication. Interestingly, only three studies in the present review examined strategies used by health professionals to deal with conflicts with colleagues in the OR [ 28 , 32 , 33 ]. Rogers et al. [ 33 ] described the type of behaviours that could exacerbate conflicts, to contribute to the development of a conflict management intervention for surgeons in the OR. Sinskey et al. [ 20 ] went a step further by conducting a review on the conflict management literature and identified the phases of conflict and described the different types of conflict management styles and techniques that health professionals could use [ 20 ]. According to Sinskey et al. [ 20 ], health professionals must first recognise the phases of conflict, then identify and apply the most appropriate conflict management strategy to use in the given context. Sinskey et al. [ 20 ] suggested three conflict management strategies in the OR that health professionals could use: (1) acknowledging and managing own emotions before reacting; (2) seeing beyond the other person’s emotions and trying to understand their perspectives, reasoning and concerns; and (3) aligning interests and emphasising common goals to identify alternative options and solutions. In another study looking at surgeon’s stress and coping strategies, Arora et al. [ 45 ] suggested that a stress-management intervention for surgeons should include the following components: (1) acknowledging stress and its impact on performance; (2) cognitive training to teach surgeons to remain calm and focused in a stressful situation; (3) practising stress management skills in a safe and controlled environment, such as simulation; (4) training as a team together; and (5) providing individualised feedback and self-reflection, for example, post-simulation debriefing. The review by Sinskey et al. [ 20 ], Arora et al. [ 45 ], along with the studies in the present review, offer valuable insights into why conflicts occur and recommended strategies that could potentially be useful in the OR. However, the effectiveness of these is yet to be determined. This represents a gap in the literature that future studies could address.

Limitations

The topic emotional components of communication included a broad range of studies across different fields. Some researchers might have described the phenomenon using very specific terms, such as frustration, aggression, while others might have discussed ideas relevant to the topic without actually using the word emotion at all, or any of its synonyms. Therefore, some potentially relevant articles may have been missed.

All 10 studies in the present review have examined negative emotional experiences in the OR. It is possible that there is a literature bias in reporting negative emotional experiences and taking for granted the positive emotional experiences that happen on a regular basis. Other studies suggested that proactively establishing rapport in ad hoc surgical teams [ 10 ] and expressing gratitude and appreciation for each other’s work [ 46 ] may create a more positive atmosphere in the OR. Future research should also consider what contributes to positive emotions in the OR and how to increase positive emotional experiences in the OR.

In this review, we identified 10 studies that described different types of emotional triggers and emotional responses to communication, and examined the ways that these negative emotions can affect communication in a surgical team. The hierarchical culture and expectations of being a leader in the OR contributed to these negative emotional experiences. These negative emotional experiences had detrimental effects on team communication, for example, health professionals withdrawing or avoiding communication with each other, which could compromise patient safety. Only three studies explored ways to reduce negative emotional experiences in the OR and none provided evidence of effectiveness. Thus, these are clearly areas warranting future research.

Funding Statement

The work was supported by the The University of Auckland.

Disclosure statement

No potential conflict of interest was reported by the authors.