Teamwork in the operating room - The role of organizational design and implications for patient safety

Abstract: The topic of this thesis is teamwork in healthcare. Healthcare is often described as complex. This description is more appropriate now than ever with the extensive specialization that has taken place in recent decades resulting in increasingly specialized physicians and nurses. While this specialization has made it possible to cure even sicker patients, it has also resulted in less overlapping knowledge and thus larger gaps between the different specialties’ areas of expertise. The method prescribed to overcome these challenges is often interprofessional teamwork. It is almost taken for granted that teamwork can make healthcare more efficient and that it is important for patient safety. Surgery in the operating room is an area where this is particularly prevalent. In the operating room anesthesiologists, anesthetist nurses, circulating nurses, scrub nurses and surgeons meet together as a team, in different constellations, to provide surgery for the patient. This thesis is concerned with the interprofessional team in the operating room, on how team members understand their common work, on how they concretely work together, and on how their practice and teamwork capabilities can be improved through organizational means. The thesis consists of five studies. The main methods used to collect data are interviews and observations using video. The video observations consisted of surgical procedures and group meetings. Depending on the purpose, the analysis of video data differed from more open exploratory bottom-up methodologies to top-down approaches, such as the usage of predefined observation protocols. The results indicate that the operating team is not as cohesive as might be assumed and that contradicting rationalities held among team members from different professions can at times result in tension in the team. A complementary alternative to the popular team training approach to improve teamwork is suggested in organizing for teamwork. The three organizational principles of team stability, occasions for communication and an adaptive approach to leadership are identified as important in order to organize for teamwork. As teamwork is associated with patient safety, this can potentially have implications for patient safety as well. The results also show that a popular routine to improve patient safety, the WHO Surgical Safety Checklist, is not actually used in reality as prescribed in the routine. This can lead to new risks if its correct usage is taken for granted and other behaviors are adapted accordingly. The perceived importance of different Checklist items and the conception of risk among its users should be considered in future efforts to improve Checklist usage. It is also shown that leadership in the operating room is distributed rather than something associated with a specific leader. This challenges traditional leader-centered perspectives on leadership in the operating room. An action oriented group method to facilitate organizational development and innovation was tested at the operating unit. The results show that the method worked well in the group and that the group managed to initiate a successful change project, but that the group’s anchoring at their organizational unit should be ensured. The studies in which this thesis is based show that practice in the operating room does not always look as expected. Methodologically, this means that methods that are capable of capturing the actual practice, such as observations, are valuable tools when studying complex healthcare settings, such as work in an operating room.