Background
Methods
Study design
Interview design
Participants
Surgeons | Nurses | Total | ||
---|---|---|---|---|
Plastic and Reconstructive Surgery | Orthopaedic, Visceral and Neurosurgery | Plastic and Reconstructive Surgery | ||
N = 13 | N = 4 | N = 16 | N = 33 | |
Work experience in years | 10.2 (±5.94) | 17.6 (±2.51) | 20.12 (±8.67) | 15.9 (±8.57) |
Current position in years | 4 (±2.54) | 5 (±2) | 8.16 (±6.71) | 6.1 (±5.29) |
Age in years | 36.5 (±4.88) | 47.25 (±5.91) | 51.85 (±8.78) | 45.1 (±10.02) |
Procedure
Analysis
Coordination behaviours and adaptive coordination strategies
| ||
---|---|---|
Task management (k = .88)* | Planning | It’s more that you see, in patients who are at a certain age and have comorbidities, that you really consider how far you can go in a procedure, what their limitation is, as far as one can gauge this, with respect to operative time, with respect to blood loss, regarding pain level… So that you anticipate, so that that one defines clear parameters. [S12] |
Task distribution | Well, that someone does not possess the skills for the task at that moment. (…) That we swap with each other, so that the distribution of tasks works again and we can carry on. [N04] | |
Prioritisation | It also depends on the importance because if there are problems with the patient, then of course I’m first going to call on one of the anaesthesia consultants, before I unpack any material. [N04] | |
Delegation | Or I realise, I need something really urgently, then I know I can send someone outside, and then it will be brought. [N01] | |
Clarification of task | For example, if there is nothing mentioned on the list of split-skin grafting, if you cannot quite close the wound, then I can ask, don’t you need split-skin, can you close the wound like this and so on. [N06] | |
Assistance | The scrub nurse in the sense that when I realise that she can’t really reach over to the surgical field, that I lend her a hand so to speak. [S02] | |
Team and process monitoring (incl. routine checks) | In the beginning, before the operation starts, there are checklists (…). We have also, in my opinion a very efficient and good checklist, it also gives a lot of security and confidence that you really think of things that are important. Everyone needs to be involved; the anaesthetist, the surgeon and the nurses. [N11] | |
Information management (k = .85)* | Procedure and patient related information | When intraoperatively some bullshit happens, when you cut into some vessel and then it bleeds or some such thing, any unforeseen events (…) that has to be communicated immediately. [S09] |
Situation assessment | I must have a willingness not to rush through this procedure as a lone fighter, but keep eyes and ears open, around me. When I hear in the background, the patient, the sound of the monitor there behind the green cloth is getting slower, there sits an inexperienced anaesthesia trainee. (…) This requires attention from all team members to the other team members, what do they need, what do they want. [S08] | |
Team member information | I need to know basically what the other person knows. If I do not know (…) I have to check. [N05] | |
Decision making | If I notice surgically for example, that’s not what we expected, then you have to discuss the plan anew (…) and that is only possible as a team. This requires communication to come to a joint decision on the onward progress of the operation. I think it is wrong for one to then decide alone. [S08] | |
Teaching (k = .94)* | Explanation/guidance | There may be an intern for example, who is allowed to do something in the OR, for example sew up a wound, and he doesn’t do terribly well or has not often sewn, then you can teach him or help him. [S10] |
Balancing teaching and other tasks | But there are those [procedures] that are more difficult, or the doctors are nervous, or it bleeds, then you have really no time, you have to concentrate on the operation. (…) Then you cannot look after anyone in addition. But most often this phase is over quickly, and then you can concentrate on the trainee on top of everything. [N07] | |
Leadership (k = 1)* | Leadership role | But I think it’s a co-dominance there, because everyone has his own specialty and for his specialty the ultimate authority. [S02] |
Change of leader | That perhaps the surgeon has the lead, but the anaesthetist says, hey, now you have to stop the patient is in pain, you have to wait now. [N07] | |
Situational and contextual drivers
| ||
Challenging moments (k = .71)* | Unexpected situations | If it’s a big case, then the surgeons can choose a completely different approach intraoperatively. Simply because vessels are not such as one had hoped, or because it bleeds more or because there is an infection, you have not seen from the outside, that can alter a procedural step considerably. [N13] |
Anticipated challenges | If an intricate step of the operation (…) where they have sewn small vessels under the microscope, which simply must be done well, quickly and cleanly, which is a step where everyone knows this is not the time to just ask some questions about something else, it takes maximum concentration. [S14] | |
Climate (k = 1)* | Communication openness/work atmosphere | But the nursing assistant, I find, also has the right, if she sees something, if what I do is not good, that she tells me that, that’s something I expect. [N16] |
Results
Coordination behaviours and adaptive coordination strategies
Task management
Prior to surgery. This is for me; each team member must know beforehand what he has to do. Only then can he fulfil his role effectively and correctly. When we disagree, we need to work out a solution. One can work this out in advance so that everyone knows what he has to do. This is more effective and safer [S08].
If the microsurgical part comes you have to prepare a microscope or whatever. And also with anaesthesia, (…) there comes a point where I need high blood pressure or relaxation or not, these are the things you can determine only during surgery and that you must or want to communicate [S03].
Actually, this is already clarified before the surgery, but if new issues emerge, we have to make this explicit again during the operation. For example, if difficulties occur somehow, that the senior physician says, I’m now taking over to do this step [S11].
Once, a trainee called me and said, I’ve cut the wrong finger (…). I then took over the operation, because he was so agitated, totally lost (…) That was such a psychological burden for him that he could proceed no further [S03].
Information management
For example, we sometimes do one part of arthroscopically and one part open. There you have to say, now we switch to the open procedure [S03].
What I want particularly (…) is that when someone sees a problem, they communicate it. (…) I want him [trainee] to say: Look, I don’t know, is this normal, is this the way it should be, shouldn’t we do it differently. This is very important to me. This is the information I need [S07].
If there is a somehow delicate step of the operation (…) where everyone knows now is not the time to ask questions about something else, it takes maximum concentration, and I think in these moments, in these situations, when you really have to focus on the manual step 100% and be totally engaged, then of course, this confines the exchange of information (…) to the actual task, the specific step in the operation [S14].
And along the way, if we have a problem, we must quickly tell anaesthesia. For example, I have recently damaged the thoracic wall (…). They [anaesthetists] told me, something is not as it should be, and I replied, the only thing I can say could have happened on my end could be just that. Then the two of them saw that it all fits and that this was the most likely reason [S07].
You can best recognise such things by, well frenetic activity and, yes, again by being reactive, no longer remaining proactive, you can tell when people are not tuned in, do not think ahead [N04].
It’s simple. When I realise I’m no longer safe, I don’t have it under control, I can no longer say that he [trainee] is not damaging anything (…) Then you notice something, you have the feeling that he had planned too little, cannot do it manually, that’s the moment where I have to react [S07].
You have to constantly monitor them operating, what they do, and then you see already, aha, now it’s a bit dangerous, now I have to have vascular clamps in theatre. Then I tell my circulating nurse, please go and get them ready, it might be that I need them [N07].
It has happened that I said, look, I’ve never done that before, but I would like to do it, could you stay in theatre with me [N16].
For example, is the cartilage damaged? Yes / No? How severe is it, how big is it? These are things that you cannot see in advance, not even with imaging methods. Then you plan, there are for example two solutions: a reconstructive method or a stiffening of the joint. These are things that we decide during the surgery. But we plan for this beforehand. (…) There is actually a kind of decision tree already prepared [S01].
Teaching
In advance you already know, that there is going to be a trainee that makes mistakes, (…) because it is a learning situation. Then you’re a bit more careful, then you’re thinking ahead, how can we prevent errors. So while I talk more, explain more, inquire if there is ambiguity, maybe I can explain already before we start, how the process might go, or any possible errors or possible ambiguities, or I ask if the trainee has seen something like this before or not. Just a bit cautious and paying more attention [N14].
Leadership
Or even if they say, give me the suture already, we want to close, but the final count has not been completed, we say, stop, no, now we count first, and only then you get it. In these cases it is very clear that you have to seize the leadership role [N16].
Situational and contextual drivers
Challenging moments
When I was very young, I was fascinated by a consultant surgeon that could solve all problems. You know huge problems, a hole cannot be closed, the flap is too short, the screws are wrong, and in the end he could solve everything. With some experience, I noticed that he had produced half the problems himself [S03].
You have to discuss the issue briefly. Usually we say this is what we have found incidentally, which we did not know of before, or we have this and that complication that we need to take care of now. Then we do it. We discuss these things on the go, so it is rarely the case that one says, stop, we put all the instruments down for a moment and discuss the situation before we continue. [S07]
These are all relevant things, that the door remains closed, that you know, you need to tell people that no one should come in unless absolutely necessary [N01].
Because there are many operations where one finds only during surgery, what exactly is going on, how we have to proceed. Often or very often you have a plan, and we know for the most part how the operation will proceed. (…) Then of course the situation unfolds. Or you have incidental findings, which then have some influence. Then you have to change the surgical plan, let’s say, rather than this we use Plan B or Plan C, etc. [S14].
Climate
To create a professional yet relaxed atmosphere where everything revolves around the patient and the operation, (…) and that it is up to me, to ask questions and to expect answers. I think that’s the most important thing [S14].