The following four types represent different ways of communicating and relating seen in daily task performance within surgical teams, based on the directed content analysis:
Proactive and intuitive communication (Type 1).
Silent and ordinary communication (Type 2).
Inattentive and ambiguous communication (Type 3).
Contradictory and highly dynamic communication (Type 4).
In the following, each citation of an observation or participant quotation has been assigned a reference number for one of 39 surgical teams observed or one of the participants - practicing as an SG, an SN, an CN, a NA, an AN, or an AN nurse.
Type 1: proactive and intuitive communication
In Type 1 teams, interdisciplinary collaboration was characterized by a broad agreement regarding shared goals, a noticeable expression of mutual respect, and timely and accurate communication focused on solving the problems that arose. Frequently, these teams performed complex surgical procedures of a long duration. The degree of complexity emphasized the need for and the importance of shared responsibility to manage daily surgery schedules in the best possible way. Communication and relationship dynamics in these surgical teams were characterized by participants being proactive and intuitive.
The proactive and intuitive communication was notable when the team members exchanged considerations about expected challenges before and during the surgical procedures, and thus solved problems in advance through shared decision making and problem-solving communication. If unforeseen events occurred (e.g. patients´ conditions, lack of surgical assistants, surgical instruments, or replacement materials needed) and there was a risk that they would cause surgical complications, cancellations, or delays of surgery, team members exchanged their reflections involving all team members expertise and experiences. Together, they searched for the best possible solutions and made appropriate decisions. As demonstrated in the following observation from team activities in the operating room [Team 29]:
The CN knows exactly which types of materials connect, although it is a very rarely used instrument. She is talking loudly to her colleagues and the surgeon about how and what to do. The SG is listening; he mentions the possible solutions and chooses materials for the replacement of the hip. However, the SG is very concerned about the vulnerable condition of the patient’s bones. “It is quiet thin!”, he says. The AN nurse enters the room and asks if they may sedate the patient. The CN answers: “Yes, we have just made our decisions about the surgical procedure and choice of materials. You may do so!” The AN nurse replies, “Okay, then we will begin sedation of the patient!” The NA works confidently with a rapidly and steady hand during their preparation for the surgical procedure. She talks about her reason for acting and gives the SN much advice. The NA gets the full attention of the other (CN and SN). They are listening and responding to her ideas. The CN nurse prepares the transportable x-rays appliance and says: “We should probably prepare ourselves that it will be done under radiolucency, when the patient's bone tissue is so thin!”
The participants knew one another’s role and expertise and took into account what was important for each other’s task execution. This was visible when the anesthetic nurse would take over tasks from the circulating nurse with the purpose of helping to create flexibility to enable an appropriate flow during the surgical procedure. This was also visible when the surgeon involved the team members in the surgical technique and the OR nurse was vigilant and aware of the surgeon’s preferences and surgical technique, as shown in this situation [Team 23]:
The surgical procedure has just begun. The SG says: “We start!” The SG shows the SA how to hold the retractors. The SN works quietly. The SG tells the SA what he sees, what he is doing and why. He speaks softly, so the patient cannot hear him. Together, they talk about the condition of the patient’s knee. The SG describes what he is going to do next. The SN focuses and prepares for what she predicts will be SG's next move or need. The SG drills the nail into the thighbone and says: “I would like to have a…” The SN hands it to him before he has pronounced the name of the instrument. The SG saws the bone. He wants to pull out a nail, but it is stuck. The SN hands the SG an instrument to pull the nail out. Again, the SG talks softly to the SA about the surgical technique. The SN holds the surgical instrument that she predicts is going to be used next; she closely follows the SG movements and action. She is right in her predictions and hands over the instruments without speaking when it is needed by the SG, as though she knows exactly what his next move is going to be.
Often, these types of teams were found to perform surgery that involved a high degree of complexity, which underlined the benefit of proactive and intuitive coordination and communication when problem solving was needed. This occurred for example in a situation where two OR nurses were preparing for a very complicated surgical procedure, and they had to connect several rarely used surgical instruments and prepare a variety of custom-made replacement materials [Team 29]:
Suddenly, the SN says: “Oh, these two… they don’t fit together!” The CN thinks and says: “Oh, NO, we have to stop him [the surgeon]. The head [one part of the replacement materials], he has chosen, doesn’t fit in.” She walks quickly to the place where the AN nurse is preparing the patient for the anesthesia and says: “Wait a minute!” Then, she walks in a hurry to the phone and calls the SG. The CN and the SN discuss the size of the different parts of the replacement materials and what to do now. The CN says: “He will come, and he is very annoyed that the person who prescribed the operation was so focused on the thighbone part, when the patient’s acetabulum is so damaged.” They continue talking about which solutions they should opt for. The SG arrives, and together they discuss the possibilities and decide. “We will continue! Never going down on equipment!” SG exclaims.
Finally, these teams expressed mutual respect: verbally as well as non-verbally, and a remarkable responsibility for the interdisciplinary learning environment in the operating room. This was observed for example when an experienced OR nurse greeted and gave instructions to the surgeon’s assistant in the operating room about the scheduled surgical procedures; and when senior surgeons´ were educating surgical assistants or showing great attention and patience towards newly employed OR nurses.
Type 2: silent and ordinary communication
In Type 2 teams, interdisciplinary collaboration was guided by shared goals and characterized by mutual respect. Frequently, these teams were performing surgical procedures on patients who underwent standard/routine surgery of short duration which required less exchange of opinions, alignment of expectations, and shared problem solving. Communication and relationship dynamics in these teams were therefore characterized as being more silent and less dynamic than seen in the other types of teams.
This type of silent interpersonal dynamic appeared when the team members performed safe-surgery procedures such as time-out and check-out. Often, the verbal exchange of information in these procedures was very brief without details on the specific surgical procedures, expected challenges, or estimated duration of surgery. Sometimes the execution of the check-out procedure was skipped despite the unit’s safe surgery guidelines.
Another representation of silent communication was visible during the surgical procedures. In these situations, speech acts between team members were informative and instructive, without preceding discussions of uncertainties, expected challenges, or decisions regarding the patient and the surgical procedure, as in this observation [Team 14]:
The SG picks up the instrument from the table and puts it back again, himself. Unusually, the table is placed between the SG and the SN. Sometimes, the SN hands the instruments to the SG and collects small bone pieces from the SG’s tweezers using a piece of tissue. Occasionally, the SG says what he needs to have. He uses the ball joint reamer [instrument for milling the acetabulum] and says, “54,” to which the SN replies, “Yes” and hands the instrument to the SG. Once more, the SG uses the ball joint reamer and says, “I need a larger number!” He gets the instrument, uses it, and says to CN, “We get a 60!” The CN points to a room outside the operating room and asks the SN, “It is outside, isn’t?” The SN answers: “Yes, and it must be the one without holes!”
Although the interpersonal dynamics in these teams were often silent during the surgical procedures, a lively conversation was observed between the OR nurses during the preparation for the surgical procedures. Typically, communication between the nurses was focused on the instruments and materials needed, but there was also a lot of small-talk or talk about social life in the unit and about personal issues.
Members of these teams were often familiar with the scheduled surgical procedures and with one another. The routine nature of the surgical procedures influenced the topics of the communication in terms of what was needed to be discussed and arranged. Team members rarely talked about surgical complications, but they always sought to be prepared for the most commonly encountered variations concerning hip and knee replacement procedures and aware of the surgeon’s preferences of instruments [Team 12]:
The SG takes off his gloves, having just finishing the surgical procedure. The CN says, “Look at these pictures [X-rays]. It is from the next patient! What did we agreed about? What are we going to do?” Then, they talk about which type of hip replacement materials they are going to use for the next patient. They walk together to the closet and look at the different replacement materials and instrument boxes. They make a choice and decide together.
Team members in these teams were communicating and acting in a manner supportive of shared goals. Goals were not always accurate, clear, or obvious; rather, they were implicit and rarely verbalized. The team members showed awareness of what was important for the task performance, for the patient’s outcome, and for each other’s function. This awareness was expressed in the following [Team 5]:
The CN says to the SG, “Would you like us to release the tourniquet [decouple the blood pressure cuff] now or do you prefer that we wait a little?” The SG answers, “We wait!” Then, the AN nurse says to the CN, “When you release the tourniquet, please tell me, because I think she is a person [the patient] who could present bradycardia when we release the tourniquet!” “Yes, of course – I will do so!” the CN replies.
Finally, it was found that familiarity, routine tasks, and knowledge of one another on a personal level established an atmosphere of fellowship and safety, which, occasionally was disturbed by an ironic tone of voice in the operating room. “This way of speaking together in the operating room is a part of our culture, we are aware of the tone, but sometimes it appears to be too much” [SN 25].
Type 3: attentive and ambiguous communication
In Type 3 teams, interdisciplinary collaboration was characterized by health professionals who were guided primarily by functional goals and to a lesser extent by shared goals. Collaboration was characterized by team members expressing disrespect rather than respect, as well as team members using blaming communication rather than problem-solving communication. These teams were found caring for patients who underwent routine as well as complex surgery. Communication and relationship dynamics in these surgical teams were characterized by inattention to one another and by ambiguous speech acts between team members.
Inattentiveness was observed when OR nurses were unprepared to follow the surgeons and their next moves during the surgical procedures, or when it was difficult for OR nurses to get hold of the surgeons prior to surgery, which resulted in prolongation of ongoing surgery or delays of scheduled surgical procedures. The team members’ orientation towards their own goal accomplishment rather than accomplishing shared goal of the team was reflected in their lack of attention and lack of knowledge of what other team members needed to accomplish their specific goals. This was apparent in the variations among team members regarding what was the most effective and efficient way of preparing for surgical procedures [Team 13]:
The SG enters and completes a very short check-in procedure with the CN and AN nurse. CN says loudly, “We have prepared for a cemented arthroplasty X [she names a specific procedure], and for this procedure we have these materials!” She points to the materials on the table and continues, “Then we have prepared for an uncemented arthroplasty Y [she names another specific procedure] and for this procedure we have these materials!” She points to the materials on another table. The SG replies, “What if it is a Z arthroplasty [he names a third specific procedure], what have you prepared for that procedure?” CN answers, “We haven’t prepared for that procedure, today!” The SG response, “Well, why not? That is too bad!” The CN answers quickly, “You can’t have it!” The SG then comments, “I will stick to my fundamental views on this case about unpacking. In general, I think it is important to think about saving money; we just take the stuff into the operating room and pack it up if we need it.” The CN responds, “Okay, but if it isn’t prepared, you would blame me if we need something during the intraoperative phase!”
Communication between the health professional in these teams was clearly different from that of the other teams observed. Sometimes communication between team members was inappropriate, and sometimes the tone of voice was ambiguous and disrespectful [Team 34]:
The team is performing check-in safety procedure. The SN asks, “Antibiotic, is it given?” The AN nurse answers, “No, it has to be given after the biopsy!” The SG adds, “Exactly”. The AN nurse says to the SG, “You’ll tell me when I am allowed to inject the antibiotics, right?” The SG says, “YES, and you will remind me to tell it! It is something one can forget!” The SG continues, “Can I say something regarding the next patient if it is suitable now?” The SN asks, “Yes, but do we have time for the next patient today?” The SG replies, “YES, we do. We are on track! The next patient should not be sedated!” He continues, now very loudly, “Are you listening?” and he follows up by forcefully mentioning the first name of the AN nurse. The AN nurse responds with a single word, “Yes.” After a few minutes, the SG has directed his attention to the SN, who is working by his side connecting the suction line and the surgical coagulator. The SN is struggling with the lines; she is focused because the lines have become tangled together. The SG says very loudly and with an ironic tone of voice, “NO, no, now you have to STOP! You must be true to your own principles! Do you hear? Before, you told me that it doesn’t work to make a Dick Turpin’s knot [a specific way of tying a knot], and now you are standing there tying a double bowline knot – yourself!”
Several of these teams were working in an atmosphere with a touch of uncertainty, and frequent use of irony and sarcasm was observed, in addition to ambiguous attitudes related to individual team members. These attitudes were sensed when observing a newly employed OR nurse and a senior surgeon collaborating [Team 28]:
The surgical procedure has just begun. The SN stands on a step stool and she has two instrument tables ahead. She is going to jump down the stool if she has to reach the instruments on the tables behind her. The SG asks, “Do you have a sand pillow?” and the SN answers, “Yes, here!” The SG asks, “Do you have a scissors and a tweezer?” He gets the instruments. The SG asks again, “Then, I must have a tread!” The SN replies with a question, “A lilac?” and the SG answers, “Yes, or a blue one!” The SG continues, “Can I get a chisel?” The SN is searching on the tables in front; she jumps down the stool and searches on the tables behind. The SG is waiting, and after a little while he says loudly, “The nurse can’t find the chisel.” After waiting a little longer, he continues, “The fact that she cannot find it, I view as a sign that she opposes me!” The SN is quiet, and she finds the chisel. The collaboration goes on the same way for minutes. The SG asks, the SN scans the tables and jumps the step stool up and down. Finally, the SG says, “Wouldn’t it be easier if you roll the tables to me?” The SN answers, “I didn’t expect you to use it!” The SG responds, “I always do. ALWAYS!” Now the CN interposes, “Isn’t he nice to you, x?” [She mentioned the first name of SN]. Halfway through the surgical procedure, the SG exclaims loudly, “This is a mess! The conclusion of the surgery today must be: It is fantastic that the surgeon finished at all!” The tense atmosphere continued.
These teams worked together on surgical procedures of varying degrees of complexity, just as frequently with standard/routine tasks as with advanced/complicated orthopedics surgery. However, when performing very complex surgical procedures, accurate and timely communication was typically observed during the time-out and check-out procedures. When routine surgery was performed, the safe surgery procedures were often poor, inaccurate, or even missing.
Type 4: highly dynamic and protective exchanges of meaning
In Type 4 teams, interdisciplinary collaboration was characterized by being inconsistent. The interpersonal interactions were highly dynamic in the sense that communication between team members could vary from being respectful, accurate, and problem-solving to being sharp, ironic, disrespectful, and finger pointing. As with Type 2, these teams frequently cared for patients who were undergoing routine surgery of short duration. Communication and relationship dynamics in these surgical teams were characterized by being highly dynamic as a result of contradictions in team members’ cooperation behaviors and personalities.
Contradictions became visible in team members responses to each other, when a sharp and commanding tone was met by silence and short answers, as shown in the following situation [Team 18]:
The SG and the SA are trying to replace the leg but it doesn’t work out. The SG exclaims loudly, “No, dammit, the monkey hand [nickname for a certain instrument], NOW!” The SG takes the offered instrument and manipulates the leg, and it snaps into place. The SG says, “Minus 4 [size of the hip material]!” and the SN finds it. Together, they check the size, and the SG responds in a sarcastic tone, “THANK YOU!” The SN is quiet and focused on her tables and the instruments. Beyond the exchange of words regarding the instruments, there was no communication between the SN and SG. At the end of the surgical procedures, the SN asks the SG, “Should I fill out the paperwork, or is it something you do?” The SG answers shortly: “Something I do!”
Additionally, this type of contradictory and highly dynamic communication was observed when disrespectful behavior and finger-pointing attitudes were met by collaborators who responded in a respectful and problem-solving manner.
Occasionally, it was difficult to determine whether the participant expressed mutual respect or not because of the ironic and teasing tone of voice. An atmosphere of insecurity could sometimes be sensed during the surgical procedures and was clarified in interviews conducted after the observation. The health professionals had developed different strategies to manage tense or strained situations with their colleagues in the operating room. Some choose silence and focused on their tasks. For example, [SG 1] “I freeze the situation or kill the discussion by not attending” or [SN 5]: “I keep my mouth shut.” Others confronted the tough tone [SN 5]: “I would tell the person that my limits are exceeded, or I would say I have a sense that you are a little annoyed today, what is it about?” Others took a problem-solving approach, for example, [AN Nurse14]: “Someone yells and shouts about how bad things are going. Perhaps I have been there before myself. Now, I am saying maybe it isn’t well-functioning, but you should move back, take it easy, and try to talk about it together.”
Episodes of disrespectful behaviour were also observed in these teams, reflected in several ways, as team members showed minor temper tantrum, used disrespectful language, argued in a commanding tone, or humiliated other team members by shaming them for being unprepared or unfocused. Such episodes of disrespectful behaviour created a tense atmosphere for collaboration, as expressed by an OR nurse immediately after a surgical procedure where this kind of behaviour was observed [OP 33]:
“I like that we constantly have dialogue about what is going to happen! For the most part, we are good at the planning part. But there are just some combinations that do not work quite well! And it marks you immediately. It does! In reality, it depends on individuals. And one can also notice that there are some surgeons and some OR nurses that doesn’t fit together! Then, the surgeon is right up in the red zone already before we start, and it spills over! I don’t like it at all. In my opinion, it is unprofessional of all parties involved, and it provides a very annoying mood all day. It might be hard, to be in for a full day. Because the room will explode if you say just one wrong word, or people jump down the throats of each other if something is upside down. In these situations, I am aware to not do anything wrong, since I know that the whole thing will explode.”
Finally, health professionals in these teams often talked about topics that were irrelevant for the surgical procedures. In some cases, these conversations served as invitations to newcomers to participate in the community of the surgical teams. In other cases, the conversations between individual team members were of a nature that excluded other team members, who then became quiet [Team 16].
The SG asks the CN if she has got a new haircut. She answers, “Yes, and haven’t you lost weight?” The SG replies: “Yes, I am going to complete a marathon, so I must.” The newly employed SN, the SA, and the AN nurse are quiet and focus on their tasks. The conversation about running continues, while they work with the surgical procedure and the CN quit by saying to SG: “You have also so much confidence and charm!”
However, these Type 4 teams were typically observed performing routine surgery, so solutions to instrumental or surgical challenges were rarely required.