This is the first study in Sri Lanka to investigate interprofessional teamwork in operating rooms using qualitative methods. Although this paper is limited to information gathered from interviews with surgeons in operating room teams from one teaching hospital, it provides useful insights into the nature of interprofessional teamwork in this setting.
The findings of this study could be strengthened by direct observation of team interactions, however, given the exploratory nature of this research and the need to ensure confidentiality for those participating, direct observation of operating room work was not possible. During informal interviews with surgeons, anesthetists, and nurses in this hospital, nurses’ involvement in the study was seen as necessary. However, as the number of surgeons, anesthetists, and nurses in the hospital is small, collecting data from all three groups at the same time was seen as potentially compromising participants’ anonymity. Therefore, anesthetists and nurses from the same operating room teams were invited to participate in the study for data collection at a later date, however, their perspectives are not included in this paper.
The collaborative nature of interprofessional work
Surgeons’ perception of teamwork revealed a lack of shared team identity-often the surgeons referred to themselves, nurses, and anesthetists as separate (sub) teams working within the same operating room. Surgeons perceived their role in the team as more important than that of other professionals and, as a result, failed to recognize the interdependent nature of the team members’ work. Attempts to integrate their work with nurses were not described, nurses were considered to be only playing a supportive role.
Surgeons demarcated clear roles for nurses, anesthetists, and other supportive staff in the team. Having such clearly demarcated roles was considered to be one of the elements of ‘good’ teamwork; almost all of the surgeons described different team members’ ability to effectively fulfil their separate roles as contributing to efficient team functioning.
Some elements of interprofessional work as described in the conceptual framework-interdependence, integration, shared team identity, and shared responsibility [
15]-appeared to be weak among the operating room teams in this setting. Demarcation of clear roles, on the other hand, was a strong element of interprofessional work. Interprofessional work appeared to be in the form of
collaboration, a broader conceptualization than the more focussed form, i.e. teamwork (Fig.
1). The collaborative approach could be applicable because of the stable composition of the teams and the less ad-hoc nature of team formation in this setting. Stability and familiarity among team members could help teams function with less integration and interdependency, however, as discussed next, these team characteristics could also act as impediments to efficient team functioning.
In some settings, stability in team membership has been important in facilitating interprofessional collaboration, however, in others, it has also created hierarchies and communication barriers, [
15,
17]. Because the number of surgeons and nurses in the hospital is small, team members tend be familiar with each other and have opportunities to form relatively stable teams over time. As described by a senior surgeon in this study, familiarity with team members could contribute to what he perceived to be efficient team functioning-because nurses familiar with the surgeon were able to better support his work. However, in contrast to other settings where stable membership helped gain mutual trust and understanding between professional groups, here it appeared to reinforce pre-existing power perceptions and help maintain rigid status hierarchies in the team. Team members’ personal history with others in the team, and their knowledge about the dispersion of power within the team, could prevent teams from perceiving underlying conflict, and addressing communication barriers. Such pre-existing power perceptions, which is the way in which team members perceive themselves in relation to their team members, can in some situations create communication barriers and veil underlying conflicts [
18].
What surgeons deemed efficient team functioning was based on their own perceptions of cooperation within their teams, i.e., nurses’ and other professionals’ ability to closely follow instructions “
like computer programs,” complete tasks without asking questions, and promptly and efficiently respond to “
commands” or “
run around” surgeons’ instructions. One junior surgeon talked about the potential for tensions between nurses and doctors, however, most senior surgeons, particularly those who led the operating room teams, believed everyone was working well together. This may indicate a breakdown of communication between members, and unresolved, unspoken tensions and conflict. Surgeons are known to lack knowledge about conflict within their teams and have been reported as often failing to perceive tensions within their teams [
18,
19]. This is often due to the large power differences-such as those observed here between junior and senior surgeons as well as nurses and surgeons-which could prevent those in the lower strata from feeling safe to voice an opinion or speak about their concerns. The team leader also plays an important team role in influencing and motivating other team members to speak up and play a role in decision-making [
15,
18,
19]. However, team leaders who take a transactional or authoritative approach to leadership can discourage team members, including their own junior surgeons from playing a role in important team processes such as, in voicing an opinion or making decisions.
Team leadership and hierarchy have been described as important team processes in various other settings [
18,
20] and this seemed to be the case here, however, there appeared to be unique relational and contextual factors, described next, that influence such team processes in this setting.
Relational factors influencing interprofessional teamwork: Professional power, hierarchy, and socialization
A prominent status hierarchy was observed within the teams, both between and within professional groups. In other settings, team hierarchies are known to facilitate and impede teamwork [
18,
21,
22]. Similar effects were also observed here; the hierarchy enabled senior surgeons to supervise junior surgeons, and by overseeing team processes and outcomes, seniors created a sense of stability and security for the juniors. However, at the same time, the hierarchical organization also disempowered juniors by limiting their participation in important team processes. Junior surgeons felt devalued because they were not contributing to an important team process, namely: decision-making. More importantly, hierarchical arrangements reinforced traditional notions of dominance, both professional and gendered forms [
19,
21,
23] creating particularly prominent power gaps between the surgeons, nurses, and other team members in this setting.
Throughout the interviews, surgeons clearly demonstrated their professional power, establishing boundaries, and separating “
us” from
“them.” The process of identifying those that are different from one-self (i.e. othering), is a phenomenon that has been documented in healthcare settings [
22,
23]. Othering can be intentionally used to reinforce and reproduce positions of domination and subordination. It is also an indication of a work culture that centers on creating valued positions for certain professions while diminishing the role and position of others. One surgeon in the study recognized that a privileged position was enjoyed by them, however, it was perceived to be the norm: “
I am not putting us high up [above others] but it’s like that.’Although it was not perceived as deliberate othering in this setting, professional groups are known to seek a relative dominance over each other for a more privileged social and economic status. Othering is often also related to professional socialization, because when individuals seek membership in valued groups, they are expected to acquire the norms, values, and attitudes associated with that group.
One of the unique ways in which professional socialization happens in this setting, and is used to maintain a relatively higher professional status, is through the language of communication between team members. Across Sri Lanka, and in this hospital, surgeons, anesthetists, and doctors, communicate in English when conducting clinical work in the operating rooms and wards. Nurses and supportive staff would speak in the local languages (Sinhalese or Tamil) when talking to surgeons and doctors and during their own socialization. As such, language could be used to create and set professional boundaries and hierarchies, and to limit socialization within their own professional groups. This is also reflected in the surgeons’ choice of language for the interview. Although the predominately spoken language in this setting is Sinhalese, all of the surgeons preferred to be interviewed in English. Use of language for othering has been described in healthcare settings in other countries, however, this is mostly documented in relation to healthcare provider and care seeker interactions [
23].
Contextual factors influencing interprofessional teamwork: Patriarchy and gender norms
In addition to professional socialization, the gendered division of labour between male surgeons and female nurses adds another layer of complexity to interprofessional work. In Sri Lanka although more than 90 % of nurses are women, the majority of surgeons as well as those in decision-making positions in healthcare institutions such as hospital administrators tend to be men [
24]. As a result the nurses’ role is always perceived as ‘women’s work’ while the surgeon’s role is perceived as work that is/can be effectively done by ‘men.’ It is noteworthy that the surgeons interviewed here always used the male pronouns “
he” or “
him” to refer to the team leaders.
In patriarchal societies such as Sri Lanka, gender norms dictate particular roles for women and men and these could also translate into an organizational culture that created hierarchies and subordinate positions for female healthcare workers such as nurses. As male doctors in general, and male surgeons in particular, are esteemed in society, the gender and power gap is prominent in the operating rooms, more so than in any other healthcare setting. For example, nurses, even those who have more experience and many years of service than the doctors, would address surgeons as ‘sir’ or ‘doctor.’
However, the gendered dimension of the work hierarchy and the gendered division of teamwork are not directly talked about by the surgeons, and this may be due to lack of gender diversity within the different professional groups, For example when all of the nurses are females, there would be no opportunities to observe and to talk about nurses’ work in gender specific terms. However, the gendered dimension of operating room work and the subordination of nurses is seen in the way surgeons describe them as those who “follow 100 % of our instructions” or as those who “run around our instructions.”
Training and mentoring junior surgeons
Other studies have shown that individuals seeking membership in groups that are valued, such as professional bodies, tend to socialize exclusively with those group members, and adapt behavior consistent with the group identity [
23]. A similar phenomenon was observed in this setting, particularly the junior surgeons, as they idolized seniors and the esteemed position held by them as team leaders and decision makers. As a leading teaching hospital in the country, this is particularly relevant for the training and mentoring of junior surgeons. Junior surgeons seem to derive their understanding of appropriate clinical practices by observing and modeling senior surgeons. Because of the lack of training opportunities to develop non-technical skills such as communication and team building skills, and/or lack of time and motivation to utilize the few opportunities that were are available, junior surgeons predominantly learned non-technical skills also by observation and role modelling senior surgeons. However, within the context of existing power and gender gaps, and the gender and status hierarchies, opportunities to observe positive interprofessional interactions and to develop mutual trust and respect for juniors, nurses, and other professional groups are unlikely to be available for juniors through this method of learning. As such, junior surgeons would not have opportunities to acquire skills that can help them improve interprofessional integration interdependence on each other, and to also develop a sense of shared team identity.